GPs and the gender clinic queues

Waiting lists are up to five years for gender identity clinics. What could GPs do?

Brighton GP Samuel Hall, who has a specialist interest and 450 trans and nonbinary patients, said that prescribing hormones and other trans healthcare is “not specialist care” and that GP practices should deliver it, though they need more training and support.

Well. Trans people want hormones. They help us transition, they help us appear of our true gender. They inhibit fertility, perhaps permanently, and medical ethics says “Do no harm”, but we would say the benefits outweigh the risks. A GP should be able to understand those risks- if there is an increased risk of embolism, monitor for that.

The British Medical Association guidance says GPs should understand gender incongruence. The Royal College of General Practitioners position statement from 2019 notes that trans patients seeking gender affirming care will first contact their GP, and the GP may be the first person they tell about their gender, but GPs are not trained in gender identity issues and are instructed to refer on. They want more research on outcomes of treatment, including “wait and see” (do nothing), and more expert services.

The BMA recognises that patients will self-medicate if we cannot get NHS prescriptions. The BMA and GPs advocate for timely treatment. The Royal College of Psychiatrists suggests GPs could prescribe hormones and hormone-blockers, but the General Medical Council advises GPs should only consider this if the patient fits all of three criteria:

they are already self-prescribing or likely to, from an unregulated source- so a GP would not take over a private prescription
The patient’s risk of self-harm or suicide would reduce, and
The GP has sought the advice of a specialist and prescribes the lowest acceptable dose.

Even though they say “untreated, gender dysphoria can severely affect the individual’s quality of life and potentially lead to mental ill-health”, they don’t seem to recognise particular benefits from hormones in themselves. Hormones do have particular risks, which they take into account as reasons not to prescribe, especially pre-op. I may have a look round to see what is established about the benefits of hormones in gender diverse adults.

So you may be able to get hormones from your GP, but it is difficult. Once the gender clinic recommends hormones, the GP should prescribe them, but that may be in five years’ time.

GPs should use the forms of address and pronouns we prefer. They should recognise our distress and the difficulty of confiding in someone. They can refer to specialists directly, and should do so.

Simon Gilbert writes that gender dysphoria is uncommon but not urgent, so GPs should be able to identify it and refer on. GPs treating risk unknown unknowns. Another GP writes he has had three trans patients in twenty years. GPs should not have to deal with trans patients “because another part of the NHS is crap”. GPs feel overworked and underqualified on trans care, and we should recognise their difficulties too. For too many GPs, managing patients means saying the right things so we use as little of their time as possible. Patrufini Duffy writes that GPs are overloaded with social problems on top of having no time to deal with their lists of patients, so cannot take on gender prescribing.

The BMA says GPs should work with us on fertility care, including sperm or egg storage.

The BMA recommends an intermediate service to provide care up to but not including surgery. There is such a service in Wales. Such a service could refer “complex” cases on to a more specialist service, but the definition of “complex” would change as its skills, experience and competency develop. The BMA pressing for more gender clinics might be a way of absolving itself of responsibility for prescribing now. It says GICs, not GPs, should manage the GIC waiting list and should not ask GPs to reassess patients in an attempt to delete some patients from the waiting lists.

Pulse, a magazine for “health professionals only”, reported on the gender clinics asking GPs to review patients on the waiting lists, and sought quotes and allowed comments from GPs.

Seven years post-op, my new GP explained that the risk of thrombosis indicated I should come off hormones. It was a disaster. I went back on; but one risk named to justify the prescription was osteoporosis. We need to be able to justify hormone prescriptions.

Picture from the Wellcome Collection shows how seriously doctors take themselves.

Men’s and women’s brains

Do trans women have women’s brains, and if so, does it matter? Do trans women think like women?

In the 1990s, I learned about the BSTc, a part of the amygdala which is twice the size in men than in women, slightly larger in gay men, and women’s size in trans women. Problem solved, I thought, trans women have women’s brains. It can only be measured by dissection, though, so is no use as a diagnostic tool, and my internalised transphobia spoke up: what if I don’t? What if that means I am not trans?

Women’s brains have more white matter. White matter connects brain areas with other areas further away. So more white matter means more connectivity. Rather than using a single part of the brain for a particular function, women are more likely to use different parts.

All brains show differences between the left and right side, from nematodes up, and Iain McGilchrist in The Matter with Things explains this is because all animals need to eat without being eaten. The left side pays specific attention to prey, and the right side pays global attention to everything going on, as predators could come from anywhere. The right hemisphere is larger than the left in both sexes, but the effect “seems to be” more marked in males.

“Seems to be”- it seems that McGilchrist does not consider there is enough research to be definite. Lay people will often not know for any common assertion whether it is based on detailed and conclusive research, on one suspect study, or has been debunked. There is more research all the time.

Differences in brain structure might produce different behaviour, but might equally well prevent differences in behaviour by compensating for other sex differences such as the effects of sex hormones. For example, the right frontal cortex is crucial in the empathy between mother and infant, so might be less well adapted to making risk decisions, as it does in the male.

Testosterone in utero makes the right hemisphere grow faster in males than females, by inhibiting left hemisphere growth. But the same level of testosterone in males and females will have differing effects, and women may use different parts of the brain for particular tasks depending on whether they take contraceptives, or where they are in the menstrual cycle. I know from taking synthetic progesterone the effect it had on me.

I don’t know that I have any particular androgen insensitivity, though once I started on testosterone blockers my T levels dropped. I don’t know what might lead doctors to check. So my brain development in the womb was probably fairly male-typical, just as my development of sexual characteristics elsewhere in the body was. An AI shown enough brain scans of trans people can discern whether other scans are of trans or cis, but that only means there are recognisable differences in the brains of trans people, not that trans women have “women’s brains”.

Researchers can find what areas of the brain perform what tasks by studies of people with brain injury, or by brain scans. Differences in which hemisphere performs a task may be missed if researchers use equal numbers of men and women.

In a study of musicians, the compositions that had the highest ratings were by composers with a brain difference which all the men, and only some of the women, had. So the dominance of men in the culturally recognised history of great composers may be in part physical, though it is also Patriarchal.

Females have greater verbal facility, and males better visuo-spatial skills. Women use words to think through a nonverbal task. Ah, I think, I have no mind’s eye, and great verbal facility. But that does not by itself make me a woman.

If I tried totting up the ways where I was more like a woman, I would be guilty of sexist assumptions as well as proven differences, and my internalised transphobia might never think the list I came up with was sufficient, even now. What makes me a woman is my ineradicable conviction that I want to express myself this way, like trans people have in all cultures for millennia. I don’t believe in a soul, or even a mind separate from the effects of neurons, so that conviction is the effect of my physical brain.

I am a woman, therefore I have a woman’s brain, even if its sex differences are not the same as cis women’s.

Puberty blockers for trans children

Do puberty blockers for trans children work? What would success look like?

Dr Polly Carmichael, director of the GIDS, started a study on PB in trans children in 2011. The Bell judgment reports that a paper was being finalised, but one of the authors had not yet responded to issues raised by the peer-reviewers. A sociologist, Michael Biggs, has published a critique of the study which anti-trans campaigners would find devastating.

Ideally, a critique would have psychological and medical expertise Biggs lacks. He appeared transphobic before he started digging: he reports that three MSc students, whom he mocks as “woke”, told him to educate himself on trans children. He quibbles about the word “study”, preferring to call it an “experiment”, because PB has not been licensed, as if he has never heard of a “drug trial”. He quibbles that “it was not a proper randomized trial”, even though such a trial would not be possible: you notice when you undergo puberty, and people around you notice too. He acknowledges that parents were going abroad for PB when it was not available in the UK. Disingenuously, in one railing against PB in children, he says the sample was too small. However, he has found at least part of the results, from newspaper articles, comments by Dr Carmichael, and from Freedom of Information requests. He says the data show no psychological benefit from PB.

GIDS does not follow up its patients after they turn 18. Well, it’s a young people’s service, and a medical service providing treatment rather than a service studying trans teenagers. Medical intervention (including follow-up) should be for the good of the patient, not primarily to increase knowledge. However, if we are to justify PB, we need success stories.

The Court in Bell heard evidence from a trans man, now 20, who wished that PB were started earlier, as that would have prevented the need for breast surgery.

Biggs comments on the first person to get PB because he was trans, who at 35, Biggs says, was depressed and “could not sustain a romantic relationship”. The report is here. It says “He was functioning well psychologically”, and that “At age 29, he had a serious relationship with a woman, which lasted for 5 years.” Five years is more sustained than some 35 year olds might have managed. It notes bone mineral density was within normal range, yet Biggs chooses to highlight that as a risk of PB.

I found Biggs’ pdf linked from the “Bayswater Support Group”, which pretends to be for parents “looking for the best support for our children”, yet only gives resources opposing transition. It is the same old stuff, from the same old anti-trans campaigners, repackaged yet again with an irrelevant name. It is attached to “Easyfundraising”, which has recorded £7.70 raised and five supporters as of 7 December.

Whether B’s case is a success or failure might depend on who is looking, and what details they choose to emphasise. I have chosen details to make Biggs’ critique look bad. I am trans. Yet his selective quotation of B’s case shows his bias.

What might success look like? Adolescence can be a horrible time, even if you are heterosexual and more or less fit conventional gender stereotypes. Gays and lesbians find it harder. And then there is trans. The comparator for the trans child is not the more or less happy straight or gay twenty-something, now in a relationship and starting a career, but the child of parents like Mrs A who originated the Keira Bell case. Having had their desire to transition uncompromisingly resisted, are children happier? If they were, would we not hear more from them?

Possibly not. They might not want the attention. But- the only one the new/old hate group can point to is Jessie Maynard, who was 16 in 2016, and wrote then that she was happier than she would have been trying to pass as a boy. However she was never assessed by GIDS. Could they not approach her for her thoughts now?

Some detransitioners write blogs, tweet, and campaign. That is brave of them. More are getting together. Soon they may be seeking damages from GIDS.

If everything really is wonderful, might some who transitioned as teenagers come forward now? The bravery would be even greater. They may pass and be living in stealth, and not want to come out as members of a hated and stigmatised group. But without their stories, it may prove impossible for any more teenagers to benefit from the treatment they had.

If someone is trans, there are only bad choices. You can muddle along in the assigned gender. This is painful and uncomfortable. You can transition. It’s a choice of denying your true self, or being your true self and exposing yourself to all the hate and prejudice.

If you transition, you can take hormones and have surgery, and make your body approximate to that of the acquired gender. It’s a problem that too much hope is attached to this. It takes years, and during the process people tend to think that it will sort all their problems, only to find at the end that it has not. We need realistic expectations of what such treatment can achieve. So, again, we need the stories of transitioned people.

That of the actor Elliot Page is not enough. He/they is particularly talented, and has enjoyed success. Compare him to other actors with similar prominence at the time of his announcement. More ordinary teens are unlikely to have similar careers. Still, it’s good for him to come out, as part of a process of normalising trans, and I am glad he feels able to transition.

Keira Bell v Tavistock Gender Identity Development Service

Update 18 September 2021: the Court of Appeal reversed the High Court decision, in part on their application of the law of evidence. It was looking bad for treatment for trans children, but is looking much better now.

1 December 2020: After the case of Quincy (or Keira) Bell, it will be exceptionally difficult for a trans child under 18 in the UK to get puberty blockers. The High Court has decided that the evidence the Gender Identity Development Service (GIDS) had to justify prescribing puberty blockers was insufficient, and children were not capable of consenting to the treatment.

The court did not consider all the benefit that the trans child will get from puberty blockers. It may be possible for individual trans children and their families to take court action to get that relief. It may be that a better understanding of the benefits from puberty blockers, or simply a better way of explaining those benefits, will enable trans children to get the treatment they need. However they will have to go through legal proceedings to demonstrate sufficient consent, as well as to convince psychiatrists that the treatment is appropriate, and the ethical and practical concerns for each will be different.

The court’s judgment discussed at length the GIDS practice, which bent over backwards to protect any cis child and avoid transition. Families may simply go abroad and go private, and have far less protection, as one family referred to in the case did.

This is how the court made its decision.

Trans with the Quakers

Someone trans was near to tears, and I wondered, have they started on oestrogen?

Trans people are accepted by Quakers except when we’re not. We are not always understood. Waiting for the morning session, a woman asked me about her friend. “She- I can call her ‘she’ because she has gone back- was going to have surgery but found a partner, and decided not to,” she told me. She wanted to ask me, as a Friend, rather than ask the woman herself. She asked, “How does that work?”

Um. If we say “Trans men are men”, and I am glad people say that, what happens if they detransition? I said, I have heard of several people doing that. It’s because there are two questions: “Am I trans?” “Will I be happier if I transition?” The answers can be Yes; No. I did not say that when someone says I wanted it so much that I could do nothing else until I did it that they are not telling the truth. Someone told me that last night, and it’s how I felt.

I don’t really mind her asking, but some would. It should not be our job to explain, over and over, simple things about trans with all these books and websites published. I told her that everyone has fairly superficial relations with a lot of people, who might see them or might neither see nor accept them, and everyone needs a few close relationships with people who accept them unconditionally. If others accept me as I am, and I can be myself without masks, what does it matter what I am wearing?

She also told me her friend had been amazed at male privilege. When she started being seen as male, she was just treated with more respect, and as a teenager she could not understand it. Why boys but not girls?

I was delighted to meet Ruth. I loved her “Be more Becky” badge. I don’t think I have talked to her since I was raging at her nine years ago. “Will you be worried about it in ten years’ time?” is always a good question: after I heard she was supporting H, I had hoped to see her. “H wants a win,” she said, which some people might object to; but well, after all this time why begrudge H a win? It would be a win for everyone. H was so clever, she told me, she would see where we should be immediately (she mimes cogwheels spinning inside her head). Other people would get there very slowly (mimes cogs creaking round) and Ruth would want H to realise: give them time to get it. She was too impatient.

We have hugged. We have expressed our sorrow for the falling out, and our forgiveness for each other, and Ruth asks me if, on the hormones, it might be right to say that- trans women are like teenage girls?

Oh fuckyeah.

It can be awful. Women learn to live with their feelings, if unlucky suppress them but if lucky just feel them and not give an outward sign, because outward signs of emotionality in women are a weapon to be used against them. And I never have. It’s like being a teenage girl.

Quaker Gender and Sexuality Diversity Community had a meeting, and the gender-critical feminists turned up mob-handed. One read out an Area Meeting Minute pledging support for “single sex services as permitted by legislation”, and I saw that as unfriendly to trans people. They wanted to challenge our speaker from Stonewall. And yet still they came out with the trope about being frightened to speak, about how women and one or two men said how brave they were to speak out. It’s as if their allies on the hard Right don’t count. They know Lefties will mostly disagree with them. Most there support trans rights.

To me, the Left opposition to trans rights is a crying shame, because they give aid to the Patriarchy wanting to suppress trans, and prevent trans people moving on. I am sure surgery, and probably taking hormones, is bad for us. Without all this hostility, trans people could find new ways of being.

What about Quakers? Quakers are supportive, up to a point. We invited a non-binary person to speak, and we value trans women as a concept. And yet I know four of us who have got into trouble with our Meetings, or been tolerated, not for long periods been asked to do any of the work of the meeting, or walked away in dudgeon. The concept of a trans woman is perfectly acceptable. No-one is going to try to dead-name us, and they talk of how brave we are to transition. But when we behave like trans women- or like teenage girls- we get into trouble. Junior Yearly Meeting minuted, “Are we presenting ourselves openly?” It’s not good to lose my temper, but being emotional is being myself.

I feel that is a shame. My depth of feeling, whether it is induced by artificial hormones or not, is a gift, and my ongoing struggle to come to terms with it is a valuable spiritual journey. I am mortified and abashed that I lost my temper that time. Given the volcanic pressures inside, I feel I do quite well to express them as little as I do. If I could be accepted as me, rather than only if I appear as a cardboard Quaker, softly and evenly spoken, never rocking the boat, Quakers would be enriched. The fear-filled reaction of “Oh my God what is she doing now?” does no-one any good.

Gender dysphoria in intersex people

It takes courage to be between genders. Many people won’t accept that is possible, the law won’t protect you, and intersex people are assigned a sex at birth rather than let the child decide later. An intersex person told me that intersex people could experience gender dysphoria because of the hormone treatment they received. She/they did not refer me to any blog posts or accounts of it, but said the experience is shared on closed facebook groups. I did a bit of googling.

In congenital adrenal hyperplasia, where the clitoris exhibits signs of penile development, but the child is 46,XX (46 chromosomes, two X sex chromosomes) there was a literature review in 2005. 250 of the children were raised female, and thirteen had serious problems with gender identity. Some of the most “severely masculinised” children were raised male, and four out of 33 had serious gender identity problems. The authors therefore recommended that the children be assigned female, even when they were most masculinised.

That is, the children were closeted from birth. You will be raised as a “girl”, or in some cases (I don’t know whether studies would be more likely on people with CAH raised male) raised as a “boy”, rather than as a “child”. There is a decision here. There may still be eugenic ideas in some people that CAH is in some way shameful. Parents should be open with a child, as far as that child may understand, and there is a decision to make about how far to be open with the wider public, in nurseries or schools. But definitely closeting, making a decision on which gender to raise a child and sticking to that, should not be the default position. Things may have changed since 2005.

Trans people would tend to think of hormone therapy as testosterone, oestrogen, and blockers. This protocol, also from 2005, says for CAH hormone replacement therapy is life-saving, because hormones necessary for survival, cortisol and aldosterone, are replaced. Androgens are secreted in excessive amounts due to an enzyme imbalance, so the therapy is to suppress them. That too involves a judgment, as to what is an “excessive amount” for an androgen. There are different normal amounts in boys and girls, men and women, and during adolescence.

That protocol admits that patient advocacy groups debate with the medical profession their decisions about hormones, and laments that some “harbour a sense of outrage about their life or treatment experiences”. Being visibly in between genders is not easy either, and I can imagine someone with CAH allowed to have a masculinising puberty might object to that later. The answer is public advocacy, so that greater variation is accepted.

We don’t know what effect hormones have on gender dysphoria. A consultant was shocked that my GP would take me off oestrogen, but the risk he named for that was osteoporosis, a physical disability not anything psychological. I know that hormone level changes can affect my mood and how emotional I get, but not what effect oestrogen and goserelin, the testosterone suppressant I used, had on my mood.

I was committed to transition. I knew I wanted to change my presentation from Stephen to Clare. Starting hormones, and suppressants, was a step on the path to it, and an affirmation from the medical profession that it was right for me. So the hormones could have affected my mood as a symbol that I was doing the right thing, and advancing towards my goal, rather than by some physical action. I heard it as, “Yes you are really female and because you are female we give you oestrogen”. I can’t see how a study might distinguish psychological or placebo effects from physical effects- and possibly the effects are so intertwined that these words, suggesting that they could be distinguished, mislead and reduce understanding.

In adolescence, it would be different. Testosterone has masculinising effects, on body hair and voice, at whatever age you take it (or if, in CAH people, it is not suppressed). But I was initially told that I could get hormones after I went full time, so I went to a private psychiatrist who would give me hormones before. That gatekeeping role increases the desire for hormones: they become affirmation.

What is preferable? CAH people who did not have their testosterone suppressed might be masculinised, and as many are raised as girls and appear happy enough with that, the masculinisation is not cost-free.

I want a society where gender and sex differences are seen as completely normal, rather than this one where we so rigorously differentiate between two sexes that those physically in between may be treated to make them more clearly one or the other, trans people are protected in law if we intend to transition from a clear classification as one to a clear classification as the other, and those who are non-binary, physically or psychologically, are seen as weird. Now, though, it is safer and pleasanter not to be seen as weird. This pressure to conform, so serious that people alter their bodies or have their bodies altered for them, harms us all, but for children with CAH, either medicalised conformity or allowing the child to masculinise could hurt a child, and be resented.

In complete androgen insensitivity syndrome, 46,XY children appear to be girls until they fail to have a normal female puberty. Of 156 brought up as female in another literature review, none changed sex in adulthood. Of 89 children with micropenis, 79 brought up as boys and ten as girls, none changed sex, and that might indicate how powerful an upbringing can be in creating a gender identity. Of 99 brought up as boys with partial androgen insensitivity syndrome, nine changed gender. I knew one, who identified as M-F trans, and later identified as non-binary.

Don’t have GRS

Personal stories of why people wanted genital surgery, and why they regret it.

The way transgender is understood in Anglo-American culture, in the theory and practice of law and medicine and in the way trans people understand ourselves (until it’s too late) puts overwhelming pressure on trans women to have genital surgery which is not in our interests. When we regret hormone treatment and surgery, there is pressure on us not to say that in public. I regret surgery, so I have an interest in this- to save others from my mistake, as I cannot rectify it- but I am not alone, evidence of regret is suppressed and evidence of satisfaction exaggerated.

The circumstances of MtF and FtM around motives for surgery are completely different.

The diagnostic criteria for gender dysphoria in the DSM and gender incongruence in the proposed ICD-11 both require a strong desire to be rid of primary and secondary sex characteristics and to have the characteristics of the opposite sex. The Equality Act protects people who want their sex reassigned, or have had their sex reassigned, though the heading is “gender reassignment”.

At the time I changed my name and went full time, I was ambivalent about surgery, but a year later I passionately wanted it. Why would you want surgery? I believe I wanted it at the time because I wanted social acceptance, or possibly to accept myself. Where a person male by genes gonads and genitals wants to dress as a woman, there were two categories they could fit- transvestite and transsexual. The transvestite is considered to be a sexual fetishist, which I found unattractive, but the transsexual had a medical condition, which I found more congenial. I felt my personality was feminine, a concept which now I consider meaningless.

If there were more acceptable categories, protected against discrimination by law, not involving surgery, perhaps I would not have wanted surgery. Medicine tends to categorise health problems which require the intervention of doctors to cure, but possibly we could reconceptualise gender dysphoria. Gender incongruence type 1 is a desire to live in the role of the opposite sex. The treatment is to live in the role of the opposite sex, using an appropriate name and clothes. Gender incongruence type 2, a distinct condition which may or may not co-exist with type 1, is a desire for hormones. Type 3 is a desire for surgery. Type 4 is a desire to subvert gender, by not fitting any particular gender role, and the treatment is to be allowed to present as you want, male, female, androgynous.

There should be the freedom to present as you want anyway, without the need for medical affirmation, but I did not feel free and medical affirmation, or a category defined by doctors, might have helped me accept myself. The health problem would be shame and distress rather than cross-gender behaviour, and the treatment to alleviate the shame and distress rather than to change the behaviour. As the medical model is about desiring cross-sex characteristics, the GICs can’t cope with non-binary people. They still demand change of name, as Charing Cross did when I first went there in 2001.

I would have said, I want surgery because I am transsexual. I am a woman and my penis distresses me (it did). In the bath I want bubble-bath to hide it (I did). I now feel I wanted surgery to be classed as transsexual and so to be socially acceptable, as demonstrated by the available legal and medical categories. If there had been different types of gender incongruence recognised by medicine and protected by law, I might not have wanted surgery or hormones.

Transsexual support groups enforced the desire for surgery because it differentiated us, the real TSs with a medical condition, from all the weirdos and perverts, just as law, medicine and the wider culture did.

Hormones can reduce fertility, possibly permanently. I wanted to reduce my sex drive because my attractions shamed me. Self-acceptance would have been a better way.

Surgery is irreversible. I mourn being mutilated, and the pain is keener because it was my choice. That choice was socially constrained, and I am moving from self-blame to rage against those constraints.

A great deal of research reports high degrees of satisfaction with treatment, and low rates of regret of surgery. I am unsure why. Possibly it involves people surveyed shortly after surgery, when I and others experienced euphoria; possibly people feel shame about our regrets. I certainly do. People are unwilling to score below Neutral in a satisfaction survey, marginal people are less likely to complain of bad treatment, and while we might open up to a qualitative researcher we might not on a survey. In my case, I have been loath to speak out because I don’t fit the accepted understanding of trans women, and might spoil it for those wanting surgery now; and I want to maintain links to trans groups. Though Johns Hopkins stopped doing GRS as they decided it did no good.

 ♥♥♥

Sylvia Morgan undertook qualitative research, trying to find difficult to reach trans people rather than using the customary routes of gender clinics and trans support groups. Post-op, most people lose touch with those sources and that might be a reason why some research reports such high satisfaction rates. Four out of thirteen post-op trans people expressed regret. That is a huge figure.

People report long waiting times to see gender clinics, and long waiting times for surgery referral once there- perhaps seven years. A friend waited longer. Another friend said the psychiatrist kept challenging her desire, saying that it won’t grow back once it’s cut off, as if she did not realise that. Of Dr Morgan’s research subjects, Lady G who wanted penetrative sex had to wait many years because she had to work in male role, as a lorry driver, and the protocols demanded the “real life test”. She also refused to fit the stereotype of a “woman trapped in a man’s body”- “I don’t know how women feel. I just know how I feel. I’m definitely not trapped. All I want is the wee operation down there.” She passes as a woman, unlike most of the MtF research subjects, and has a strong sense of being one.

Kylie, though, felt hurried. She was not sure how she felt and questioned the conclusion of her first half-hour consultation that she had “insight” and an “excellent understanding” of the transition process.

People used The Script, saying they felt trapped in the wrong body, felt they were not of their assigned gender from very young. “People play the game to get what they want.” Dr Morgan reports that discussions in support groups are dominated by medical procedures and visits to the GIC, and I observe that on facebook, with regular delight at getting surgery or despair at the delay. It is a way of getting status in the groups, that you are seeking surgery. Four said they had never considered medical procedures before joining support groups.

Phoenix felt pushed through a process. She had said she did not particularly want surgery, but had it three years after her first referral to the GIC. She drifted through the process and does not know how she got where she is, post-op.

Vida first went to the GIC in March 2010, and had surgery in October 2012, having pushed for it. She was processed quickly because she demanded progress. There appears to be little consistency in procedures and protocols. Waiting times appeared arbitrary. One psychiatrist was described by many participants as condescending, patronising, clock-watching. Trans women felt disrespected, as I did.

We want medical recognition in order to get legal recognition, so we have surgery as that is what the medical model requires. The participants wanted a vagina in order to “feel fully female”, rather than for what one would do with it: gynephile trans women still go to surgeons who can give depth. The psychiatrists generally did not attempt to dissuade them. (We would hate it if they did, denouncing them as cruel gatekeepers.) Yet the surgery is a symbol of being a woman or truly transsexual, rather than a choice because of what the penis and testicles can do, or the neo-vagina can do.

Dr James Bellringer, who does NHS vaginoplasties, said the backlogs were “spiraling out of control”. In 2013/14 they received over three hundred referrals yet did 180 operations. “The nature of gender surgery is that the vast majority of these referred patients will go on to GRS,” he said.

Iain, a gender queer trans man, thought better of it. The effects are irreversible… there’s so much that can go wrong… it sounds like a world of pain and struggle and scarring and infection.

Oestrogen is a symbol too. Subjects perceived it as enhancing emotions and gentleness, but one reported that her powers of concentration were a lot worse, another that she was considerably weaker, making her job more difficult.

As hormones and surgery are primarily symbolic, that one is really trans, entitled to legal recognition, others as well as I feel euphoria after finally having surgery. But then Carina reported that reality hit her like a big sack of potatoes. Surgery does not mean social acceptance, necessarily, and the body has to heal its effects. The neovagina is in effect a wound, so you have to fight the healing process with dilation.

Vida felt recovery took two years, and had further depression ten years after surgery, “because there is no aftercare or support”. Dolores said she had not understood how difficult and time-consuming dilation would be: “A lot of girls just don’t bother with the dildo, they just let the vagina close up”. Lily agreed. “Nothing really prepares you for what happens afterwards.” I think when some people go for the gender reassignment there is a hope for changing your life, starting a new life, but then it’s still just you with your same problems, and after the surgery you have more to worry about… Some of them just give up, they stop dressing in female clothes and everything.

Sally hoped surgery would give her psychological relief and social acceptance, but it brought neither. She had had profound ongoing depression since transition. Trans support group organisers told me not to talk about my personal problems, not to talk about being depressed since my surgery.

People determined to get the surgery are kept in the dark and fed on bullshit. Nine out of 28 participants had attempted suicide, some more than once.

While people are taking hormones and having surgery for validation as a true trans person rather than for the actual results treatment will provide, there will be inappropriate treatment, and social pressure to have treatment. I know what the desire for the operation feels like. I felt it. Now, I feel betrayed.

 ♥♥♥

When T-Central linked to this post, Calie wrote, The last two T-Central featured posts were based on very successful transitions. One from Halle, who has transitioned, and the other from The Transgentle Wife, the spouse of one who has transitioned.

This post is from Clare Flourish who has regrets. It is important to read both sides.

I will add that I know many who have transitioned and are happy and I know some who are not. In all cases, it seems that the lack of love in the life of those with regrets, or the lack of a job, is often the case.

Clare mentioned in a comment to her post that there is pressure to physically transition. I have seen this and know several who gave in to that pressure. Some are happy. Some are not. Clare is one of my favorite bloggers. She is just lovely in her pictures and I do hope things will turn around for her.

I am grateful for the link and kind words, but I am glad I transitioned. It was how I found myself. I feel transition could mean something different, that it does not need the monolithic full-time + hormones + surgery. I feel people should be encouraged to find those parts of transition which work for them, without imagining they must come as a package.

Some of the comments below go into these issues in depth.

Norethisterone V

It seems my choices are to take Oestradiol only, and completely lack energy so that if I do my washing in the morning I just want to slump in the afternoon, or to take synthetic progesterone, and have febrile energy manifesting in highs I don’t fully trust- I seem rational, but its my Norethisterone brain doing the judging- and crushing lows.

I phoned the Samaritans, wanting to explore this low, quite how bad everything is. I would go into the darkness, and start by saying “I am not suicidal” to reassure Helen (or me). Thinking of how to express that I realised, “I want to die”. I don’t trust myself to look after myself.

The low is deep but I know it will end. That is an improvement. The high on Tuesday was really good. Even low, I feel more energy and purpose. Georgia O’Keeffe wrote, I’ve been absolutely terrified every moment of my life – and I’ve never let it keep me from doing a single thing I wanted to do. Well, I have mostly suppressed my terror below consciousness, and it has stopped me doing things, or even knowing what I want to do. Her way is better. I don’t trust my rationality, but having more energy may be worth that cost. Feelings pass.

As a benefits adviser I dealt with a man who cared for his mentally ill sister. She would do things like wander off at 2am without shoes on, and he would try to keep her safe, that is, well-managed. She was getting DLA high care low mobility, the most she could get, but he wrote to the benefits office asking if she could get more. Rather than telling him “No” they sent him a review form, and decided she should get less. He was distressed by this. She was calm, well enough fed, irked by his control as walking off in the night is fairly harmless, really. He was constantly stressed.

We did the tribunal, he was stressed, picking up various bags and papers, shaking, and she whispered to me, “Help him, Mr Languish”. So I helped him with his bags, and she was quietly caring for him.

It feels I have a carer, looking after the Inner Child, because I do not trust that spontaneous being. I trust the carer to understand the world, but the carer understands no better, is as insane as it imagines the Child is, and does no better than the Child would. The Carer’s first ambition is to avoid the Child having painful feelings, rather than to keep me safe, and it does not manage that, just anticipating painful feelings and worrying about them, and avoiding action. It falsely imagines that is “keeping me safe”. The Catholic Meditations are on getting rid of the Carer, an emptying of all the contents of the ego-consciousness to become a void in which the light of God or the glory of God, the full radiation of the infinite reality of His Being and Love [or, perhaps, the Child] are manifested. It quotes Matthew 10.39, He who loses his life shall find it.

Before today’s low, I discussed all this with Tina. I could lose my income, yet then was sanguine. All I could do was monitor the situation: no point in worrying. Life is bearable, with the occasional pleasing sensation. It is only not bearable if I imagine that I cannot stand this, there is too much unpleasant emotion. I might think that my current existence, at home most of the time, is not enough. I can get more pleasing sensation by noticing more: if I go into that state of awareness of my surroundings, particularly outside, there is a great deal of beauty and the state itself feels lively and energised.

I don’t know if I want more experience. I judge that I ought to. I find what I want when I see what I do. I do what I do. I feel dissatisfaction. I do not want to put plans into practice, as the Carer anticipates defeat.

I see a need for Advance into Greater Spiritual Maturity, and I am working on that. I am coming to appreciate my own good qualities.

I don’t trust the benefits system. It claims to pay a very low income to people unfit for work, but does not keep that promise. If some people in a wheelchair might not qualify for ESA, its criteria are far too strict. And I think I have identified the Gotcha moment, the moment where I could not have known but she seems, now, to have decided I did not score particular points. I am frightened.

Tina asks, are there any human systems which don’t make promises and fail to live up to them? Well, in 1948 the benefits system was more honest. Now there are deliberate cuts, and intended holes in the safety net. And we never manage perfection, just imagine it- each person differently. What we achieve is good enough.

-What do you hope for?
No idea.
-You might get it then.
That is a good question, and I shall go away and consider it.

I have now been blogging for six years.

Norethisterone IV

My dear friend Richard explained to me that I transitioned because I misunderstand what femininity is. Well, of course I do, but I feel he simplifies it worse. My father, a pansy, found a virago, and they were married for 33 years. Then 18 months after she died he found another, who is now his widow. He was happy.

We had some difficulty on finding the right word. I want to be- dominated? No, no, yuck, the connotations of leather, pvc, whips and chains revolt me. Subordinated, perhaps. Ruled, even. Those words will do. He says this is inauthentic, a cop-out from the existential duty Sartre called all human beings to. Yeah, right- so tell me again why Sartre had a fifty year relationship with a woman who was cleverer than he was.

I said that if I were a woman seeking a man, wanting to be dominated would be unremarkable, and at that he said no, only equality is acceptable within a relationship. Why should my father not be happy? Or I? He insisted, and then said I misunderstood femininity. He accepted it was cultural. Women are strong. I agree equality is a good model for a relationship, yet feel “Wives be subject to your husbands as you are to the Lord” is OK if that fits the people involved- and the other way round, too, for some couples.

What would a gay man know about it anyway, I wondered. Possibly he was projecting, but as we were getting a little heated we agreed to change the subject, and went onto politics.

I have enough norethisterone to have ten nine-day sessions of it, at the dose I had been on. I find that it makes my emotions more intense, so came off it, and the endocrinologist said I should not take it, but I wanted to experiment. At times, more intense emotions could be fun or a learning experience. This is day three.

I arrived a little early, and phoned his house in case he had not left yet. When we had poured the tea, I noticed a tedious chord progression in the background music- I V VI IV repeated, eight semiquavers to each- so unimaginative- and complained about it. “That sounds like Batman”, he said, Nananana nananana… I put my hand up to stop him, embarrassed and peremptory. Ah. Possibly that’s the norethisterone. Its purpose with HRT is to prevent endometriosis, and as I have no uterus, it has no value. My needs and desires have greater immediacy, and then I find myself apologising and explaining.

Sartrean authenticity may be impossible.

Testosterone overdose

Men in the US increasingly take testosterone supplements. This can lead to impulsive decision making. Hypo-gonadism, causing low T levels, can make a man fatigued, and uninterested in sex, which can be cured with T; but men with ordinary T levels are taking T. What is the effect?

Men and women were given the Cognitive Reflection test, which is a series of maths or logic puzzles with an intuitive, wrong answer and a need to think carefully to get the right answer. Eg, a bat and ball cost $1.10, the bat costs $1 more than the ball. How much does the ball cost? Not 10c.

Men and women given a testosterone boost are less likely to analyse carefully. They care less about what other people would think. They are more likely to think they outperform others. In simulated asset trading, they were more likely to overprice assets, and slower to recognise that prices were falling.

I got all that from the NYT, and recall a factlet from something I read some time- after watching a football match, fans of the winning team had increased T levels, and fans of the losing team had decreased T levels.

More impulsive decision making could be worthwhile in a leader. Where are the mammoths we need to hunt? If our best way of working it out is magic with mammoth bones, it’s better to just guess. We need a decision and it almost does not matter what that decision is. Other people will be grateful for leadership.

In the more complex modern world, good decision making takes account of a wide variety of expertise, and a testosterone-inspired random plumping may be sub-optimal. The problem is, only the women notice.

If high-T males rampage through life damaging things, and women trail in their wake, fixing the mess, the man might never realise he had made any false steps. However the research does not prove that high-T is a bad thing, just that a sudden change in hormone levels can discombobulate a person. I knew that already.