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It’s Not About Surgery

by Sequoia Elisabeth

Anyone in the Transgender community knows what the treatment for Gender Dysphoria is. As stated by WPATH, Treatment for gender dysphoria varies with severity of symptoms, but may include counseling, crossdressing, contra-hormone therapy, and surgery. Here is an article which explains the nuances quite well. It is so very important to emphasize the counseling rather than the surgery in my opinion for several reasons. This obviously will be different for each person, so take this with a grain of salt.

The Transgender journey to me is all about acceptance, both of who you are and what you have to work with. So if someone goes out and modifies their appearance and/or function (SRS/GRS) does this really change who they are? This may or may not help to alleviate the perceptions of the individual and those who meet this transgender individual. From my experience, invasive treatment is really beside the point and offers nothing more than something to compare with. Meaning, you have a different presentation and perhaps this feels good at first, but after a while you realize it just doesn’t matter. The roles you play are different, but you are still that same person at the core (with the same mental/emotional issues). Let’s face it, we are all playing roles in society and these roles seem to define us, but do they really? Does the fact that you are working as a mechanic or a mother or a manager really make you who you are? Or is it the other way around? You define the roles! At least this is the way it should be in my opinion. So by defining a role you decide if women are good mechanics or if hair dressers are bitchy. You; not your gender defines the role.

So the transition journey is really about coming to an acceptance of who you are or to say it more simply, liking yourself! We all go through this process and transgender people have just chosen to do it by way of gender. Substance abuse is another way to “find yourself” and come to an acceptance. There are many challenges we each unconsciously choose as our own method of spiritual growth! You are probably engaged in this process right now in your own way. The good news is no matter which path you choose the Universe conspires to make it the most productive learning lesson it can be.

We each define our own parameters for what is acceptable to a certain extent; however we are each a part of the whole and society is one aspect of that whole. So why do we allow society to dictate these parameters? Because we are part of the whole! So then it becomes a matter of conformity. I find it interesting that most people consider themselves non-conformists, but they are still a part of society and in their own way conforming to the greater whole (myself included). It is my understanding that we each make up one part of this whole and that we are each different.

So why not just be this different person and stop trying to conform to a perceived reality? This is in fact my vow, to be myself and be happy with who I am. Yes, I was born male and yes I feel most comfortable in women’s clothing, so what? I am attracted to loving people, not to body parts. I wish to be loved just like everyone else! And I wish to be that loving person within my own comfort zone, which with some effort is constantly expanding.

The point here is that surgery and hormones are a tool for an effect, but they do not change who you truly are! If others have difficulty with your appearance or behavior that is actually their issue not yours. Continue being your authentic self and loving it! Why? Because the other choices are just not any fun, at least not in the long run.

Sequoia Elisabeth 🙂

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How Necessary Is SRS?

by Sequoia Elisabeth

When is surgery for Gender Dysphoria appropriate and necessary? Should a doctor do the sex change just because an individual says they want one? Gender Identity is a person’s own concept of who they are – it cannot be proven by science, so does a person’s word stand as gospel? These are questions care providers specializing in gender must deal with on a daily basis. The rule many are adopting lately is the informed consent rule, while others stick with the WPATH Standards Of Care (SOC).

Let’s look at both to see what works best. The WPATH Standards of Care 7 was just released in 2011. It is put together by specialists in Gender treatment, including physicians, surgeons, psychiatrists, psychologists, and therapists. One of the first things they point out is gender non-conformity is not the same thing as gender dysphoria and should be treated differently depending on the severity of the individual’s condition. It is largely the mental health care provider’s responsibility to guide the individual to a discovery of the extent and intensity of discomfort or dysphoria they are experiencing and if this experience is constant or intermittent. A copy of this publication can be downloaded for free at this link. (http://www.wpath.org/publications_standards.cfm)

“Surgery – particularly genital surgery – is often the last and the most considered step in the treatment process for gender dysphoria. While many transsexual, transgender, and gender nonconforming individuals find comfort with their gender identity, role, and expression without surgery, for many others surgery is essential and medically necessary to alleviate their gender dysphoria (Hage & Karim, 2000).” (SOC 2011) (Italics and Bold added)

Informed consent as I refer to it here is not the traditional form used in all medical procedures for legal reasons, it is simply the verbal understanding between patient and provider of how the individual identifies and then treatment ensues based on the individuals testament. It is used because as stated before no one can prove a person’s gender identity. Even the individual may have doubts about it which are to be taken in consideration by the provider. This is why counseling therapy is so important in my opinion; because if the person has other psychological conditions they may get the idea they are transgender when it is simply a masking by this overlying condition. It is also good to get several different opinions to confirm the person’s gender dysphoria before prescribing hormones or doing any surgery. The big difference is the SOC method recommends a letter from a licensed practitioner and the informed consent method does not. The provider just takes their word for it.

Obviously the question of which works best is still being worked out, so I will leave it to you to decide while sharing my opinion from experience. The SOC have been in use since 1979 and takes a conservative approach to treatment. The informed consent method is more cavalier and puts the responsibility squarely in the hands of the individual which may be the appeal for both the practitioner and the patient; however I question if it is really in their best interest.

To wrap this up it is every individual’s responsibility to ask questions, do research and know as much as possible before reaching any conclusions or taking any actions. Make sure you know which method your provider uses and what is required of the individual in the treatment path. Trust your gut! Or to say that another way, listen to your soul. It knows the path you need take and get a second opinion before making any life changing decisions like living full time, taking hormones, or having surgery. It is my opinion that surgery is a last resort used in the most severe cases of dysphoria. I also believe that everyone, yes even cisgender individuals experience gender dysphoria although it is often a brief experience precipitated by an external event perhaps through someone else’s dysphoria. There are other types of dysphoria also, like the feeling you are from another world or are really a non-human being, but that is another story all together! Those individuals are referred to as Wanderers if you would like to do further research. Till next time readers, Blessings on your Journey of Love ♥

Sequoia Elisabeth 🙂

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Gender Surgery Other Options

by Sequoia Elisabeth

On the topic of surgery related to gender transition there are many options these days. Each person will have different desires and resources so this blog is very general. Be sure to discuss more specific concerns with your gender therapist or contact me. I am happy to answer questions.

Gender Dysphoria is the medical term assigned to transgender and transsexual individuals who are uncomfortable with their birth sex. The issue is the gender identity and the physical sex are non-congruent (do not match). Thus the new medical term of Gender Incongruency used now.

The treatment for this has evolved over the years and it has been found that while the genitalia are important other areas of the body are even more important in successful gender transition. The face and breasts are key attributes of being female or male! So it makes sense to alter these first and foremost to alleviate the dysphoria.

It is also important to remember the reason for any gender surgery is to alleviate the dysphoria and align the individual with their perceived gender identity. Everyone deserves to be comfortable in their own skin! Facial Feminization Surgery (FFS) and Breast Augmentation Surgery are two methods of treating Gender Incongruency which may be more important than even the GRS, although some individuals have it all.

Some of the other more minor surgeries being done are trachea shave, liposuction, buttocks enhancement, rhinoplasty, hair implants, botox, and lip enhancement. The list is only limited by your imagination!

For the Female to Male transition breast reduction and hysterectomy are the important surgeries. FtoM transgender transition well with CHT and some only have the “top” surgery (breast reduction) depending on the level of dysphoria. Removing the ovaries is important to CHT making treatment more effective.

Another option of treatment for the MtoF is Orchiectomy. This is the surgical removal of the testis without any cosmetic changes. This procedure is inexpensive comparatively speaking at around $3,000-4,000 USD, it may be available for less depending on the surgeon and geographical location. The purpose of this surgery is to remove the production of testosterone and thus eliminate the need for anti-androgens in the transition thus avoiding the cost and side effects. Estrogen is still used in varying amounts depending on the timeline of transition. The first three years are critical for a successful transition, so it is vital to remain on estrogen continuously for that period. Those who are on and off CHT do not feminize well. They are left requiring surgery for all their feminizing. (The patient is taken off all CHT several weeks before surgery and then resume afterwards depending on doctors orders, this is unavoidable and has minimal long term effects, i.e. the benefits outweigh the costs/risks)

The CHT when used properly and as early as possible will preclude the need for FFS and Breast Augmentation in most cases. So these surgeries are mostly for individuals who transition later in life. Great care must be exercised in deciding the need for surgery! It is a trap that many are falling prey to now days with the explosion of cosmetic surgeries being done. The addictive qualities of almost instant gratification are not to be underestimated. Proceed with caution.

The transition journey is about learning to love yourself for who you are. Drastic surgeries are helpful in some cases; however it is easy to abuse technology! It is recommended that gender therapy be sought out first before any thoughts of surgery are seriously considered. Once you are sure surgery is right for you do the research to find a surgeon that can deliver the results you desire.

The number of qualified surgeons specializing in gender surgeries is growing all the time, so look locally and consider all your options. Just as in any surgery consider your motives, the consequences and the costs (not just money).

Imagine the results you desire and stay focused on this. You can also use your imagination to decide what exactly you desire, although actual experience has no substitute. If you feel like being with the same (birth) sex then do so and then decide if you desire GRS or other surgery. Be as clear as you can because there is no turning back! (Even though some have tried). When you are intimate with your partner how do you feel? Is this different than other times?

Blessings on your Journey of Love!

🙂 Sequoia Elisabeth

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Gender Surgery

by Sequoia Elisabeth

Continuing from the previous blog post, doing research concerning transition and Genital Reassignment Surgery (GRS) is very important. The older term SRS (Sexual Reassignment Surgery) is still used by some. Please review this page in the Gender Learning Center (Click here) for assistance in your research.

SRS/GRS is not as complicated as one would think. The procedure has been done now for over 50 years and lately the surgeons are getting very good at it. Some of the issues to be concerned with are logistics, cost and convenience. The skill of the surgeon is a very hot topic and while this is important, it is not as big an issue as it would seem. Depending on where the surgery is done, most countries have strict standards doctors must abide by, especially since surgery and medical care has become a commodity that brings in big money. Thailand and India are emerging as world leaders in this market so they definitely deserve a close look and your consideration when it comes to choosing your surgeon and location. The price you pay is many hours in a plane traveling across the world to save a few thousand dollars. When you can barely sit down, being in an airplane for 20+ hours is not appealing. Of course there are options to cope with this such as meds and cushions. From what I hear it is worth the trip.

The USA has several very good surgeons now doing SRS/GRS, so look closely at the local options. Most gender therapists will know who they are as do the gender support groups. I will not list them here because I would leave some out and that is not my purpose here. The informational sites I list on my website do include several surgeons, however I chose them on the basis of information provided, not on how good the surgeon is. If you have questions or need help finding someone close to you I am happy to assist. See the website Unity in Gender Diversity.

Logistics includes things like travel, housing, post care, assistance during recovery, preparations before surgery, documentation (passport, proper ID, surgery letters from your therapist), and medical records. Each surgeon will have requirements for you to meet, and they give ample advanced notice in most cases, however it is prudent to research this, so you are prepared. Call it peace of mind.

Cost is an issue that we all are acutely aware of. Many options exist however it is recommended that you get references from the surgeon you choose and make sure the location has the resources to provide safe and effect treatment in the event of an unexpected emergency. The costs include, travel, housing, food, surgeon fees, hospital fees, operating room fees, anesthesia fees, and medicines. Most surgeons have package deals so make sure exactly what you are getting and what will be extra. The recovery time is at least two weeks and many take as much as six weeks, so another cost is time off of work.

Convenience is the last but not least concern when choosing a surgeon and location. It is not to be under estimated. From the many post op transsexuals I have talked with, being able to travel a short distance to the surgery center and home again is a real plus. The horror stories of being on a plane for hours and hours is something to consider carefully. Take into consideration your age, possible side trips, who will be with you, and your travel experience. Those who are seasoned travelers will be more inclined to go far to save a little money. I also hear that sightseeing in places like Thailand can make it all worthwhile. Don’t rule out locations such as Europe, Mexico, Caribbean, India, or Canada. Check with your local Gender support group for those surgeons who are close to you and be sure to check credentials and review customer satisfaction of others who have experienced their services.

Sequoia Elisabeth

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The Gender Sexual Connection

by Sequoia Elisabeth

Sex: The physical sexual organs, what is between the legs. This can change due to sexual reassignment surgery; includes male, female and intersex.

Gender: Separate and different from an individual‘s physical sex or sexual orientation (hetero, homo, bi, or asexual), it is an individual‘s perception of the inner self as man, woman or some combination of both, transgender.

Operating from the above definitions we now know that gender and sex are very different and yet from experience we also know that they are intimately connected. How do we work out this connection? Is it meaningful?

Sexual Orientation is the trait we give the most attention because it involves others. Who are you attracted to? Why? Does gender really have anything to do with this attraction? How important is appearance? What about body parts? Some people are turned on by toes and if this is the case does it matter what is between their legs? What if ears are a turn on, the same question applies. You are probably saying that what it leads to is very important and this is where the genitalia come in. I agree completely.

In the transgender world we offer a contradiction to this process. Our parts do not match the majority of the human race. So do we have GRS to conform or is it more practical than that, simply to enjoy sex in a manner which supports our mental functions? Many transgender women have surgery just because they cannot bear having male genitalia. It is like having a large growth on your body which causes you distress. It could just as well be a tumorous growth! In this case having surgery is medically necessary, as much as any person with a tumorous growth. When the result is a happy well adjusted individual post op it is hard to argue against GRS/SRS.

“As an effective treatment for a specific mental disorder, sex reassignment surgery is as deserving of public funding as any other psychiatric treatment.” states Dr. Ray Blanchard, head of the Clinical Sexology Program at the Centre for Addiction and Mental Health. (Egale Canada ©2011)

“The reported 68%-86% overall success rates for sex reassignment surgery must be viewed cautiously; the lack of long-term follow-up studies makes these statistics misleading. There is evidence suggesting that some gender dysphoric patients benefit primarily from sex reassignment surgery. Most such patients, however, are secondary transsexuals who can benefit from various modes of psychotherapy. Sex reassignment surgery should only be considered as the last resort for a highly select group of diagnosed gender dysphoric patients. As physicians learn new ways to diagnose and treat transsexualism, either sex reassignment surgery will be abandoned as a routine treatment modality or new predictive variables for choosing suitable patients for sex reassignment surgery will be established.” (Lothstein, Am J Psychiatry 1982; 139:417-426) The above quote is a bit out dated now and this author finds it interesting that its prediction is far from correct. SRS has grown in popularity as surgical techniques have been perfected. It is now the best treatment known for severe gender dysphoria. The question remains, what if the dysphoria is mild? What constitutes mild? This is between the patient and their counselor or therapist.

The final point or question I wish to raise is, does sexual orientation figure into ones decision to have surgery or not? From the clinical perspective, the answer would be no. Dysphoria is separate from sexual behavior and needs to be treated regardless of sexual orientation. The practical side of the issue is a personal one. Transsexuals often start off in same sex relationships and to have surgery would destroy the identities associated with the relationship, so unless both individuals are flexible the relationship ends. This is even the case in heterosexual relationships since it would be homosexual after surgery. Those relationships that do survive often forgo sex altogether.

One of the most difficult aspects of the transgender journey is relationships and the changes they must go through along the way. The losses are often heart breaking, but this is not necessarily a bad thing. It can lead to more loving and authentic relationships! The road has many potholes, so it is best to proceed with caution.

🙂 Sequoia Elisabeth

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To Be Or Not To Be

by Sequoia Elisabeth

To have GRS (Genital Reassignment Surgery) or not, is sort of like the question “to be or not to be”? It is a choice all gender variant individuals must answer. Of course we could get into the terminology game and define the different stages of the transition journey, but we will not. (Please see how I define terms here) Take me for example, (because I don’t like to speak for others) I have identified as no less than 7 gender identities including man, woman, androgynous, crossdresser, transvestite, transgender, and transsexual. I am not sure many others even exist, except for maybe queer or genderqueer and in my day that was a very undesirable label. I hated that label almost as much as being called Lurch. To say I have an identity crisis is an understatement; my life is an identity crisis! Or is it?

The reality is life is always growing, changing, and experimenting with various forms of existence and humans are no different. How many people do you know who are happy with only one outfit, one flavor of cake, one of anything in their lives? It sounds absurd to me to even think of living in the same house all your life, from birth to death. Many have done this and that is the beauty of nature. If it is possible then it has occurred at least once.

Variety is the spice of life! So how you identify is up to you and it does not have to be set in stone. Crossdressers identify as their birth sex, but like being the other from time to time, so they dress in the clothes of the opposite sex. To me this is not necessarily a gender identity issue. It certainly is not an illness or disorder. It could however be classified as a fetish. The point being here is these individuals have no desire to have GRS.

I like to think of gender as a rainbow or sliding scale. The scale runs from male to female and has many degrees in between. It looks like the graph to the right. The other factor which confuses things is a person can fluctuate on the scale from day to day and even moment to moment.

So how does one decide that GRS is right for them? This is the million dollar question! It is not a decision you can reverse. So taking it seriously is highly advised. Getting in tune with your inner feelings and experimenting with different lifestyles and roles is important in reaching this decision. How do you feel most comfortable? Are you sure? Is is always this way or does it fluctuate? If it fluctuates to any degree then maybe you should wait on GRS. I have seen several different statistics indicating that most GRS candidates are happy post op and the numbers of people feeling they had made a mistake are few in comparison. WPATH guidelines were design just for the purpose of assuring only true transsexuals or severe gender dysphoric individuals get the surgery.

So what do you do if you are in the middle somewhere? Gender Dysphoric but only mildly and able to live in the birth sexes gender role. This is a choice for the individual ultimately, but a professional specializing in gender issues should be consulted for at least 3 months and preferably for a year or more. From my experience it is often other issues that depress the individual making gender dysphoria a secondary condition. Again this is why it is so important to have professional help.

Next time we will discuss sexual orientation and its role in the GRS question if it has one which I feel it does. Gender Identity and Sexual Orientation are different, yet connected, like much of life!

🙂 Sequoia Elisabeth

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Genital Reassignment Surgery

by Sequoia Elisabeth

As I said in my earlier blog posts, doing your research concerning transition and SRS/GRS is very important. I can help with this process since I have done quite a bit myself. Please check out this page in my Gender Learning Center (Click here).

The USA has several very good surgeons now doing SRS/GRS, so look closely at the local options. Most gender therapists will know who they are as do the gender support groups. I will not list them here because I would leave some out and that is not my purpose here. The informational sites I list on my website do include several surgeons material, however I chose them on the basis of information provided, not on how good the surgeon is.

Convenience is the last concern when choosing a surgeon and location. It is not to be under estimated. From the many post op transsexuals I have talked with, being able to travel a short distance to the surgery center and home again is a real plus. The horror stories of being on a plane for hours and hours is something to consider carefully. Take into consideration your age, possible side trips, who will be with you, and your travel experience. Those who are seasoned travelers will be more inclined to go far to save a little money. I also hear that sightseeing in places like Thailand can make it all worthwhile. Don’t rule out locations such as Europe, Mexico, Caribbean, India, or Canada. Of course I moved to the San Francisco bay area because there are at least three surgeons here that I can choose from and I will not have to travel at all.

🙂 Sequoia Elisabeth

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SRS/GRS Treatment Planning

by Sequoia Elisabeth

Where does SRS/GRS fit into the treatment plan for Gender Incongruity(GI)/Gender Identity Disorder(GID)? The terms GRS (Genital Reassignment Surgery) and GI (Gender Incongruity) will be used from here on to make this flow easier. The diagnosis has been made and you are now in therapy, so what next?

The answer to this question is really up to you and your therapist or physician. There are no rules here so I recommend doing your research and getting to know the options as well as getting to know yourself a little better. Your therapist should be helpful in guiding you in the decision of whether you need GRS and where to place it in your treatment plan. It is not their decision to make though, it is yours. Please understand that you are responsible for finding your way to relief. The professionals are there to help and provide guidance.

The next step is to decide if you have enough funding to get the surgery soon or will it be years before you can afford it? If you have money or the resources to get it, then you have several options. Even if you don’t have the money now, you have options. Here they are. Get an orchiectomy right at the beginning (if you are FtoM – hysterectomy) so you do not have to take hormone blockers. For FtoM it just makes the testosterone that much more effective. Any cosmetic surgeries desired can be done later in the transition as is convenient. After fully transitioning and living in the chosen gender and knowing you are happy, get the full GRS. This option makes the most sense to me, however most doctors are uneasy with this choice, probably because they are not the ones with discomfort. (Reproduction desires need to be addressed also, since this option sterilizes)

The next option is to get hormone treatment and electrolysis done and after going full time as your chosen gender, have GRS done and leave cosmetic surgery to last. The reasoning here is financial and basically goes in order of importance and cost. This seems to be the most popular option chosen, for obvious reasons. Start where you are and take a new step each day toward your ideal.

Those with lots of money sometimes get carried away with the surgeries and do all kinds of physical alteration without fully embracing the changes emotionally. From my experience this is a difficult path and somewhat backwards. Gender transition is an emotional process and the surgery is meant to assist in the assimilation into society. Where the surgery is very important, so is taking the time to learn what it means to be a woman when you were raised as a man, or vice versa. Jumping in with the surgery can lead to disaster when you have changed your appearance and not your self concept.

When I first started my journey one of the questions I asked my therapist is where does GRS fit into my treatment? (I already knew I wanted it, and most of us do) He told me it does not matter if you get it early or later, the important part is to break down the false persona you created to fit into society and allow your natural self to emerge. The surgery will re-enforce your feelings and make it easier for you, but does not really matter to a person who will never see between your legs! GRS is for your own satisfaction in knowing your body reflects your self image.

🙂 Sequoia Elisabeth

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Is SRS Really Necessary?

by Sequoia Elisabeth

This is first in a series of blogs on Sex Change Surgery, so the obvious question “Is SRS/GRS Really Necessary?” Right from the start I will concede this is a loaded question; however, it is a question I have asked myself many times. The answer is as individual as the person considering it. The answer should NOT be undertaken alone and should be a consensus by medical professionals trained in gender issues and the transsexual individual. The bottom line is no one can tell you what your gender is! Gender is self determined, however the treatment for Gender Incongruity or Gender Dysphoria as it used to be called is a complex issue that requires guidance. I am not saying it could not be done alone, only that is much easier and more rewarding when support is provided by caring professionals, friends, and family.

With this being said, it would be foolish to jump to a conclusion when something as drastic as SRS (Sex Reassignment Surgery) or as some prefer, GRS (Genital Reassignment Surgery) is considered. The question of other conditions being present such as mental illness, birth defects, medical conditions etc. needs to be ruled out before surgery is implemented. Just as a doctor considering a liver transplant will make sure the patient does not have any other severe conditions which may hamper recovery from the surgery; it is only prudent to take an informed approach. Thus we have the WPATH Standards of Care which recommend a thorough medical work up, Psychotherapy evaluation, CHT (Contra Hormone Therapy), and living at least a year in the chosen gender to avoid the possibility of erroneous Gender Incongruity diagnosis.

The treatment for Gender Incongruity (GI) or GID (Gender Identity Disorder, as it used to be called) is the surgical adjustment of the genitals to conform to the gender identity of the individual. Counseling and/or psychotherapy is part of both the diagnosis and the treatment. Dealing with an issue this large should not be undertaken alone. At the very least a person with gender questions should see a professional that specializes in the treatment of gender disorders. There are resources online that will help to identify those professionals, please see this link (take your time and read carefully).

Getting back to the issue of “is it necessary” I offer another link to a blog that considers this issue nicely. Having been on this journey for a long time, I will share my personal experience on this question after having talked to many pre and post op transsexuals. I only know of a few cases of post op transsexuals who were not happy with the surgery. Three of those were media hyped cases of individuals who were mislead by society. Personally I have known only one person (a pre-op transgender) that transitioned with hormones for 10 yrs and then decided to de-transition and live in their former role.

On the other side of the coin I have met dozens of post op transsexuals who tell me it was the best decision they ever made. They lead happy productive lives just as they did before they transitioned. The variation in the success of SRS/GRS is as varied as the individuals undergoing the procedure, however it is my firm belief that if this option was not the best choice then there would not be so many surgeons doing the procedure today and it would not be considered medically necessary as it is by the AMA, IRS and some Insurance Companies today (see above links). It is true that not many Insurance companies will cover SRS/GRS, but their numbers are growing as is the mainstream medical communities support for this treatment of Gender Incongruency.

Choosing to undergo SRS/GRS is not something anyone should take lightly, however it is a viable option nowadays that offers excellent results of both form and function! It is time the rest of the medical community step up and see that Gender Incongruity is a serious issue that has viable treatment options with excellent results.

🙂 Sequoia Elisabeth

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