medical

Insurance approval

I know to most cisgender people this doesn’t sound significant but I just got word from my surgeon’s office today that I got insurance approval for gender confirmation surgery!

This is one of those things that should be a normal occurrence. But for trans people, we have had to fight so hard for generations to get these surgeries covered by insurance that it is still a big deal for us to have these basic rights. I remember not that long ago when my friends were going to Thailand because that’s the only way most people could afford to get surgery out of pocket. And because of that legacy, there are still so few surgeons in the US that even those of us in major cities like Seattle have to travel out of state and incur huge expenses to get these surgeries.

It’s also significant because of the amount of medical gatekeeping we have to endure to get there. I can’t think of a single procedure where a cis person has to get more than one letter of support. But most trans people require 3 letters from MDs, therapists, and PhD level psychiatrists to get this insurance approval.

For me, I got these letter last fall because I was told the surgeon was going to ask for insurance approval in late winter. But they waited too long to submit paperwork so I had to go get the letter updated because they needed to be within 6 months. Which meant that the first time around I got an insurance denial which was scary even though I knew why.

The point of this story is, if you have the authority to be a medical gatekeeper for a trans person, PLEASE make it as smooth as possible for them. There are a variety of reasons that trans people don’t want surgeries and shouldn’t need them to transition. But for those of us who do, we are usually overwhelmingly sure that this is what we want. So don’t make it harder for us than it needs to be. Trust us to be the experts on our own experiences. And if you get asked for a perfunctory piece of paper, just sign it.

41 days until surgery!

I’m down to less than 6 weeks before gender confirmation surgery and I’m so nervous! I’m not anxious about the surgery itself other than a natural concern about the rare complications. I’m nervous that something will happen between now and then to prevent me from getting the surgery. Because the idea of delaying it sounds like torture. When I did my consult a year ago, I was ready. And now I am wishing I had started the process sooner.

I’ve done literally everything I can do. I’ve bought medical supplies, collected comfortable clothing for the recovery, changed our original flight plans to a roadtrip, booked an accessible AirBnb, and even scheduled my pre-op bloodwork. But my brain can’t stop focusing on all the things that could go wrong.

What if there’s a new wave of COVID-19 cases now that we are re-opening businesses prematurely? What if I get sick right before surgery? What if I get down there and find out that the hair removal wasn’t sufficient because I missed 2 months due to COVID shutdowns? What if the doctor says that my weight is too much of a problem since I’ve put on 20 pounds in the last year?

The last one is the one I hate the most. I’m a very fat positive person and generally I don’t care about my weight. But last year I had a bad experience with Dr. Satterwhite when I consulted with him and he was hyper-focused on my high BMI. He claimed that if I gained any more weight it would be “unsafe” to do the procedure. Thankfully Dr. Wittenberg, the surgeon I ended up choosing, told me that they are more like guidelines for optimal results which I absolutely agree with, but my brain is still anxious about it. Fatphobia is one of the few remaining socially acceptable forms of overt discrimination.

In the end, there’s not much I can do about it. I know all the data about how fad diets don’t work and can cause more medical issues than they solve. And luckily the nutritionist/therapist I’m working with agrees and is helping me balance my food in a way that feels appropriate to me. But the voice of that fatphobic doctor still haunts me. I also wonder how many fat trans people he’s turned away and made believe that they can’t get surgery.

On a more positive note though, my job is being super supportive. They have hired new permanent and temporary staff to take on my workload while I’m gone with enough time to train them before I go. So now I know I can leave even in the midst of a busy period of running COVID research studies and know my work is in good hands.

Currently I am hoping to be able to return to at least part-time work after 6 weeks which is the minimum time my surgeon recommends. Since we are completely online now it should be more accessible. But there is a potential that I may need the full 12 weeks before I’m lucid and off pain meds.

For housing I was lucky enough to find a basement apartment owned by a gay couple to rent that not only is ground floor but has a kitchen and even AC! It was very expensive at $3,400 but it’s centrally located in San Francisco so I can easily make it from the hospital and to my follow up appointments without sitting in traffic. I’ll be staying for a full month since I need to arrive 5 days prior to surgery for my pre-op and stay for 3 weeks after for post-op check ins before I’m cleared to travel. I’m really hoping that I can handle the 800 mile drive home without too much pain since I don’t feel very safe about airports right now.

I’m in the final countdown period and I am so excited! Thank you to all my friends who donated over $2,500 to make this happen. And I couldn’t do this without the support of my wonderful spouse who will be my caretaker after surgery. I guess you could say it takes a village to make a vagina.

Bottom Surgery is still a Go!

I’ve been on edge ever since this pandemic started because I have been so worried that my bottom surgery this summer would be postponed. But today I got confirmation that I can re-start laser hair removal to prep the area this weekend. And based on what the surgeon’s office has said, I think I should still be able to get enough of it in by July 29th to head down to San Francisco for my August 3rd gender confirmation surgery.

I’ve changed my plans and instead of staying with a friend-of-a-friend, I will be staying in an Airbnb so that we can maintain social isolation. My spouse and I will also be driving down instead of flying because as asthmatics, airports are a pretty big risk. And I don’t know what the visitors policies will be like at the hospital during my 3 days there after surgery. But damn am I glad that it is still happening.

Lately all the little things have been bothering me because my body just can’t wait to get this finally resolved. I am grumpy about having to use my hands to pee. And I hate everything about my balls. But it is only 68 days away now! I am almost there.

Boob update

2 years and 1 month into hormones and my boobs are still growing! At this point I’m solidly a C-cup but they are pretty conical and haven’t rounded out so I don’t really have cleavage yet. Other than the shape and distance from each other, this is about what I was hoping for. It makes me so happy to see them in the mirror or my peripheral vision!

For my fellow trans health nerds who are wondering, I started by ramping up to 6 mg of oral estrogen sublingually spaced throughout the day and eventually backed down to 4 mg where I am now. I never added spironolactone (an androgen blocker) because my testosterone disappeared and never came back. In February this year, my estradiol level was 139 pg/mL (cis woman range is 12-498 depending on cycle) and serum testosterone was only 13 ng/dL (cis woman range is 8-48).

Do Trans Women get Periods?

Do Trans Women get periods? Absolutely.

As someone who is on my period now, I can tell you that it is very real and it sucks. I am ready to burst into tears at a moments notice and I could definitely bite someone’s head off right now. I’ve been tracking my mood cycle lately to confirm that it actually does follow a monthly pattern and my app was spot on this month. And it is synced up with my nesting partner so I knew it was that time without even asking her.

Do we bleed? No. But if you try to point out how “lucky” we are are some BS like that, I will slap you. Because that is a really sore point for someone like me who wants nothing more than to be pregnant. But I also know that it is unlikely to be possible while I am still young enough to do it because while uterine transplants are absolutely medically possible, they are only given to cisgender women.

The period is mostly caused by being on estrogen but I have always been sensitive to monthly cycles. Years ago before I had admitted to myself that I was trans, I noticed that my mood cycles were related to where my partner was on her period. But now that I am on estrogen it is a whole lot more emphasized.

And in case you think I’m making it up, you should read what other trans girls say.

First surgery prep laser

I had my first laser hair removal session on my genitals today to begin prepping for bottom surgery. I’ve been dreading it all week because it is so extremely painful when I do it on my face that I assumed it would be even worse on such a sensitive area. But I was pleasantly surprised. I don’t know if it’s because the numbing cream works better on the thinner skin (it did last longer), or because it is a wider dispersal laser head but it was a breeze and over really quickly. It honestly hurt a lot less than waxing or sugaring.

Turns out the worst part of laser down there is the shaving. It is a pain in the ass (literally) to try to get it all and the aesthetician still  had to clean it up. I recommend having a friend or partner help you shave. The other part that sucks is the insurance approval process which took me three months of pestering.

But session 1 is finally over. I have 6 more months of doing this every 6 weeks and hopefully it is enough for surgery. I’m also going to finish laser treatments on my face since I had to stop because it is expensive to pay out of pocket ($300 every 6 weeks). But the stubborn hair patches that have come back are giving me too much dysphoria to keep waiting.

84499459_10157817476009360_8496163687717928960_o

My skeptical face as I wait for the numbing cream to work

Inheriting a fixer-upper

I just scheduled my jaw surgery to do the first part of correcting my bite for mid-May. It’s something I’ve been dreading for the last 10 years since my dentist identified the root problem. And I’ve been surprised at how many emotions around surgery are coming up for me now that it is an undeniable reality, not just about this procedure but about my plans for bottom surgery.

My original plan was to get my jaw surgery out of the way this year and then go in for vaginoplasty next year. And in the interim I was going to meet with the surgeons I was interested in when they were in town for Gender Odyssey. But now I feel like that plan has come crashing down around my ears (like most plans have in my life).

I found out a few weeks ago that my jaw surgery is so intensive that they need to split it into two separate procedures with a year of expanding my top palate in between. So now I have another surgery on my face to dread but at least I have jaw feminization included to look forward to. Unfortunately that means I have to rethink my whole plan around bottom surgery.

To complicate things further, I found out that Gender Odyssey isn’t in Seattle this year and they aren’t doing a conference for trans adults this year anyway. So now there’s no opportunity to meet with them that doesn’t involve investing in travel. I feel like I need to decide whether to try to attend Philly Trans Wellness where I might meet some potential providers (although not my top choice – Heidi Wittenberg), or whether to travel to San Francisco to meet with them directly.

And trying to figure this all out while I’m also undergoing intensive laser hair reduction on my face (I put electrolysis on hold for now because it was too slow) just feels like so much. I feel totally overwhelmed by how far I still have to go before I’m done with all these medical procedures and honestly I’m feeling pretty despondent and hopeless about it all.

I just want to fast forward to a point in time where I feel like my body is my own. But instead I feel like I inherited a fixer-upper house that needs major repairs to be livable and every time I fix one thing, another breaks. I know that all these surgeries and procedures aren’t going to fix everything but I still have to rest my hopes on life getting easier once I’m past it all. Because without that hope I don’t know how to keep going.

This is one of those points where I really wish I had been born with a brain and body that matched and I didn’t have to go through all this work just to be myself. And sometimes it feels like I should just throw in the towel on life and give up. Don’t worry, I don’t actually have plans to do so but I can’t say I haven’t thought about it.

Anyway, I don’t know where all this is going right now other than hopefully forward even if it takes a painstakingly long time to get there. I know I wouldn’t be able to keep wading into the fray if it wasn’t for my partners and friends so I am very thankful to all of them for keeping me going. I know things have to get worse before they get better but I really hope I turn that corner soon.

Starting Electrolysis

I’ve passed the point of no return (queue Phantom of the Opera music). I’ve started electrolysis on my chin which means the beard is never coming back. I now have a quarter sized patch which is all inflamed at the moment where the hair has been permanently killed using a combination of electric current and heat to create a chemical reaction of lye to remove the whole follicle. And boy howdy was it painful!

I didn’t use a topical anesthetic this time and I definitely regret it. At first it wasn’t too bad. It was similar to tattoo needles but with the added weird sensation of radiating heat in your skin. But after a surprisingly short time, my body stopped ignoring the pain and by about 45 minutes I was begging for the hour to end. And the worst part was that it really wiped me out after. My body was just so exhausted that I came home and crashed.

Actually no, I take that back. The dysphoria caused by letting my stubble grow in for 5 days was the worst part. By this weekend I just felt gross and ugly in a visceral way. And when I added the pain to it on Sunday afternoon, it pushed me over the edge. All I could manage was getting high on pain relieving cannabis (legal here) and playing video games. Engaging my brain in Mass Effect Andromeda was the only way I kept from dissociating.

I feel much better today now that I’ve shaved. But it is odd to have a pink scabby spot on my chin that I’m acutely aware of. It is really going to take a long frickin’ time for that circle to grow to the size of my face. I’ve got a lot of sessions ahead of me but I’m glad that I found a trans esthetician to do it. I feel better about the sheer amount of money I’m going to be spending knowing I’m keeping it in the family. Hopefully next time with lidocane it will be better.

With the NYT article that is going around (which shows one valid point of view not representative of everyone), I think it is worth pointing out that the level of dysphoria I experience now is not something I expect to last forever. Starting my transition has made my dysphoria and mental health worse in some ways and better in others. It’s not a linear path but I do think that it is similar to facing any trauma – the only way out is through. The path to healing and authenticity is painful and dredges up a lot of feelings that have been buried. But that doesn’t mean it isn’t worth it or that it is a disease that I am looking for sympathy for. Treatment does help reduce dysphoria significantly but it’s a long game. You don’t get fast results.

What it does mean is that we need to reduce barriers to care for trans people. I so often hear the argument that things like hair removal shouldn’t be covered because then all the cis people should get it too. But that comes from a lens of equality rather than equity. Trans people have the most barriers to healthcare of pretty much anyone as a group. There are not only barriers from gatekeeping but the added burden of increased rates of employment and housing discrimination that keep many trans people in low paying jobs without coverage. Hair removal for many trans people is a crucial step needed to reduce gender dysphoria and if I didn’t have the money and life circumstances to be able to afford it out of pocket I wouldn’t have the ability to improve that distress.

So today I’m thankful for all the people who have supported my journey thus far. And for my job with decent medical benefits that allows me to start planning for bottom surgery (after I save enough for all the travel and associated out of pocket costs). And for my incredible partner and chosen family I live and share costs with that makes it possible to live near Seattle and still have money for things like electrolysis. I hope every person can find the kind of unconditional love that I have.

Jaw feminization

I just talked to my oral surgeon about what can be done to feminize my chin, the biggest source of dysphoria for me at this point, when I go in to align my teeth this Winter. This is a major oral surgery I’ve been dreading for almost 10 years now as I waited for the right insurance and financial stability to make it possible. But now that there is the possibility it could make my face more tolerable, I’m actually excited.

I started the process 2 years ago when I first met with the surgeon before I was out and thinking about what the impact of my prominent, square, cleft chin was. I’ve been using my beard to cover it up for so long that I sometimes forget that this really ugly-feeling part of me is underneath. I found out just how much it would cost and realized I needed a new job to make this work. The next step was the braces I got installed in January which re-align my teeth back to where they will need to be after the surgery. Unfortunately, in the short term, the braces have made my dysphoria and confidence worse. The first day I had them I dissociated so badly that I felt like I was walking around viewing the world through a long, dark tunnel. It has gotten better since but I still can’t wait to get them off.

But the end of stage one is finally in sight so I got up the courage to reach out to the surgeons office to find out if there were parts of facial feminization that could be accomplished as part of this procedure. I was both excited and terrified as the appointment got close this month fearing that he would just dismiss my concerns and focus on function. But it went surprisingly well. For an old white cis dude he seemed to really get it. He talked about the various things that he can do to tilt the lower jaw back, shave off the harsher edges, and bring it more in line with the rest of my face. He even was aware enough of the gendered aspects that he is suggesting increasing how much of my upper teeth are visible when my lips part because apparently that is a feminine trait.

He was cautious about over-promising and he is limited with how much he can do because of the potential impacts on my breathing and sleep apnea and the amount of muscle I have on my chin. But I am hopeful that it can be enough better that I can actually face myself in the mirror without my beard. He promised to do some advanced prediction models and show me several options we can discuss at our pre-surgery appointment so I can have some say in how my new face will look.

I’m especially excited for this since my insurance doesn’t cover facial feminization. And overall that’s not really a primary concern of mine on the rest of my face since I have great cheekbones (even according to the surgeon) and a good nose that balances my face. So if I can get this all done in one surgery that I’ve been planning for so long, I will be very happy.

Now to see if I can actually live without the beard for the next few months before surgery. I haven’t gotten up the courage to go into the barber yet…

Sex vs Gender: two sides of the same coin

So I know a lot of trainings, including many written by trans people, like to separate sex and gender into different concepts. But in my experience they aren’t all that different and are so integrally tied that you can’t actually separate the two. From an external perspective I think sex is what you are assigned at birth because doctors and parents make an assumption about a binary future for you based on your genitals (and sometimes force surgeries on intersex babies if they don’t match that vision because sexual characteristics aren’t binary either). Gender is what people assume about your genitals and often your behaviors and experiences based on visual cues later on. They are just two sides of the same coin. The only real difference is what external markers you are using. When I was born they assumed I was male based on my genitals and now people assume things about my genitals based on signs such as my beard and build.

Well this gets complicated of course when you are trans or nonbinary. You can do a lot to change your external appearance through clothing, hormones, and surgeries. And since sex isn’t actually based on chromosomes since most people have never been genotyped, I think those changes arguably change your sex tangibly as well. I don’t think I am a feminine person with a male sex. I now have breasts and an estrogen dominant body that is clearly and visibly nonbinary now. I would need to make major alterations at this point via surgery to go back to being a male.

So when I see forms that ask me what my sex is, I get annoyed. You can ask me what my sex assigned at birth was as a data point if you need. But my sex and my gender are the same thing viewed from different lenses.

Now internal gender is a lot harder to define but that’s a post for a future day.