Transitioning to the Feminine Spectrum
Thank you to Mercedes Allen from AlbertaTrans.org for allowing us to adapt this from her original document
Standards of Care and the Real Life Test
The following assumes that you were assigned male at birth and wish to transition to a feminine identity. Transition is in fact not the only choice available to you. Some choose to live more androgynous and challenge notions that society has about gender. Others are happy with part-time crossdressing, either alone, with a significant other, and/or with a community such as a crossdressing club. There are also those who look at the difficulties with transition, the potential loss of friends/loved ones, the social biases they would have to face, and choose not to change (or to wait).
It is our belief that no choice is an invalid choice. A transsexual may have a wider range of experience in some areas than a crossdresser, but that by no means makes the crossdresser's experiences or motivations any less valid. If a transsexual chooses to remain non-operative, that is her prerogative, and does not somehow make her ingenuine. A transsexual who chooses to slip into hiding in society once they pass, or a crossdresser who remains in hiding are no less worthy because they choose to live in stealth -- it takes a very specific type of person to be an activist, and this responsibility should not be expected of everyone. These are all valid choices, and given the exact same circumstances in our own lives, we might be compelled to make those exact same decisions. Ours is a fractured and marginalized community as it is. We need to find our commonalities, respect our differences, and find our strength together (even those living in stealth are more than welcome to the information and support on this site). We are sometimes all that we have.
The Official Process
If you need to transition, the official process is long, and you will have to be certain and committed. Once you begin, you make serious changes to your body that often cannot be reversed. Also, the waiting lists for the doctors who oversee this process are extremely long, so be prepared (acting sooner is better).
That's the bad news. There is good as well. But it is not a decision to be made lightly.
Before all of this, it is an extremely good idea to get out into the trans community, meet like-minded folks, and get a good feel for whether this is for you. Chances are, you'll meet some great, supportive people, and get a chance to get a balance of information, and some idea of where you will be on the other side of this journey. It is invaluable to have people to turn to with those questions and concerns unique to our process.
In addition to the above, I recommend that you read Calpernia Addams' excellent Transsexual Road Map site, detailing pretty much all the necessary considerations and steps to be taken along the way. It could stand to be better-organized, but it really does have the best information for the new transwoman.
The Gatekeepers
Gender Dysphoria (transition is currently addressed as a mental health issue) is not something that many psychiatrists deal with. At the moment, the two doctors referred to as the "Gatekeepers" (they may not like that term, it is a colloquial reference) who can start the process, are Dr Donna Hendrickson in Saskatoon (306-668-0505, 505 4th Ave N) and Dr. Anne Bellows in Regina (306-766-7800, 2110 Hamilton Street).
In order to see them, you will need to get referred to them by your G.P. If you don't have a family doctor, a walk-in clinic doctor will be able to do so for you as well -- however, every doctor's reaction is different, and some may refuse to do so, or may say they'll refer you, only to later say the referral must have been lost in interoffice mail. It is also possible to get a referral from a psychologist or another psychiatrist.
Once the referral is sent, you may still have to wait a long time for your appointment. Dr. Hendrickson's waitlist can be several months, and she switches back and forth from taking new patients to not taking new patients (contact her office to see if she is taking new patients). Dr. Bellows has set aside openings for new trans* patients, so be sure the doctor making your referral makes a note of Gender Dysphoria (it will make the difference between a 2 month waitlist and a 6 month). Do not harass the clinic -- it will not get you seen faster. However, you can call the clinic a week after your referral request to make sure that they received it. You can also request at that time to be put on a cancellation list, meaning that if there is a cancellation sooner, you might be able to get in at that time. It can shorten your wait considerably.
One way to cope with the waiting period is to proceed as best you can with transition with your G.P.'s assistance, preferably also with the help of a supportive psychiatrist or psychologist and an endocrinologist. It is possible to begin your "real-life test" (RLT, i.e. living completely as female) before meeting with Drs. Hendrickson or Bellows (make sure there is a paper trail, so that you can point to an accurate date that you went to living full-time), and it is also possible to find a G.P., endocrinologist or psychiatrist to prescribe hormones and monitor them. In this way, by the time you first meet Dr. Hendrickson or Dr. Bellows, yours may be more a question of finalizing the details before seeking approval for GRS. More doctors can be found on the Trans-Friendly Doctors Lists.
Hormones
Drs. Hendrickson and Bellows should be able to refer you to an endocrinologist once you pass your initial interviews. It is usually the endocrinologist who prescribes the hormones, and is best able to monitor this part of the physical process. Your G.P. is actually able to do this as well, but most don't, as most are unfamiliar with proper hormone levels required for transition, or are relatively inexperienced with this.
Please note that some doctors may not prescribe hormones, or prescribe greatly reduced levels, if you are a smoker. This is because smoking closes the estrogen receptors, and in some cases, hormone regimens are almost so ineffective as to be a waste of money. It is actually recommended that if you are transitioning MTF, that you should quit smoking. Caffeine also has a detrimental effect, though not as severe.
TransSask does not recommend "black market" (non-prescribed) hormones. However, if you do start doing so, please discuss this with your doctor -- if they know that you are doing this, feel ethically compelled to continue the process. At any rate, because of the potential serious side effects of hormones, it is very important that your health can be monitored by a doctor.
On the other hand, if you are seeing a doctor for hormones, make sure to educate yourself. The Transhealth program in Vancouver has information which discusses both FTM and MTF hormone regimens. An unfamiliar doctor may prescribe levels too low to be effective. If your doctor is open to the idea but inexperienced, it might be good to have a guide in hand. Leslea Herber has prepared excellent feminizing HRT guides as follows:
Please note that hormones are not to be played with. There are sometimes those who wonder about taking hormones to increase breast size, but with no intention of living as female. Hormones will do much more than this -- they will soften facial features, round out the hips, bring on mood swings (it is very difficult for males to cope with the severity of the change), quite often they will cause sterility, and the penis will shrink, and not return to its original size. Sex drive will be greatly reduced as well. This is only for those who are serious about transition.
The effects of hormones always range depending on the types used and the individual physiology. Not everyone will be affected the same way. However, transwomen usually do experience significant swings in emotion and bouts of depression during hormone therapy. Some transwomen report increased irritability, others report an overwhelming sense of calming. There is a loss of strength as fat and muscle mass are redistributed, and there is also usually some loss of energy.
Breast Development -- This is always a long process. It takes teenage girls years to develop theirs, and it will take us years to develop ours fully. The amount of growth is determined largely by genetics, and yours will probably be just slightly smaller (by about one cup size) than your mother's and other women on your mother's side of the family. Growth will not increase or occur faster by increasing hormone dosage. During the development, breast tissue will become very sensitive, and occasionally itchy or sore.
Standards of Care and the Real Life Test
Current medical practices follow the WPATH Standards of Care. Currently, the medical community treats Gender Dysphoria as a mental health issue, even though there are now provocative medical theories that may lead to a biomedical theory of causation. The WPATH SoC guides psychiatrists in this process, and dictates much of how transition is handled. The theory is that there needs to be a real life test, roughly a year in length, in which the patient lives and works full-time as their chosen gender. This RLT needs to be fulfilled before GRS surgery is prescribed, and partial fulfillment of this is sometimes considered required before prescribing hormones or lesser surgeries (though this requirement has been now removed from the SoC). There are cases, including patients who are older or with certain medical conditions, in which the gatekeepers might see fit to shorten this period. But the point of it is to make sure that the person transitioning will be able to function, live and work as their preferred gender and that they are fully committed to doing so.
Lesser Surgeries and Concerns
These can differ from person to person. Many of them fall under cosmetic, though, and the costs are often the responsibility of the person transitioning. Such things include breast augmentation, facial feminization surgery, laser hair removal/electrolysis, hair extensions/transplants/rejuvanation.
It is highly recommended to start facial hair removal as early as possible. Laser hair removal can be particularily effective with a qualified, trained doctor on staff (very few have one -- be choosy, and be wary)... but laser hair removal is only really effective on darker-colored facial hair against light skin. Don't be fooled by claims to the contrary, and be aware that this is not a regulated industry. Some also indicate that laser-treated hair sometimes returns after a longer period of time. For more information, Andrea James' Hair Facts site is an excellent resource.
For MTFs, it's a good idea to start facial hair removal (laser or electrolysis) before hormones, as the skin becomes more sensitive afterward. Body hair removal is usually not nearly as painful, so afterward is fine.
Breast augmentation has grown considerably in the past few years. A simple Google search will find you many options for surgeons in your nearest city.
For MTFs, estrogen does not feminize the voice. Transwomen will have to retrain their voices, and this sometimes requires professional voice training. Christie Ife at the Adult Speech-Language Centre in Saskatoon City Hospital (306-655-8181) provides speech therapy to trans women. This is an 8 week service (2 hours/week), and is offered once per year when a group of 6-8 clients has been established. Christie Ife takes self referrals (you don't need a doctor's referral).
The tracheal shave to reduce the appearance of the Adam's Apple is not covered by Health Care, nor is further cosmetic work. Voice surgery is also not covered, and is extremely dangerous. Many people going this route have experienced long-term damage.
Orchidectomy (a.k.a. orchiectomy, "orchie," or castration) is usually done at the time of GRS. However, orchidectomy is available through the Saskatoon Urology Associates, and is most often performed by Dr. Saul Gonor. Dr. Gonor follows most GRS surgeons recommendation, that the surgery be done by a midline scrotal incision, and to save as much of the external tissue as possible (discuss with your surgeon, first). If the orchidectomy is not performed correctly, there will not be enough external tissue for GRS (vaginoplasty). Dr. Gonor has also removed scrotal tissue, should GRS not be desired. Remember, removed tissue can NOT be reattached. Make sure this is the right choice for you before proceding. TransSask also highly recommends visiting a fertility clinic to explore the option of freezing sperm. Many trans women have found themselves later in a long term relationship wishing they could conceive a child. Keep your options open. You can never tell what the future may hold for you.
GRS
"Sexual Reassignment Surgery" (or Gender Reassignment Surgery, as it's starting to be called) is a single procedure, and it has been well-perfected. Results tend to be virtually indistinguishable from the real thing, and success rate has been mostly very high. Thorough, extensive aftercare is required, however.
The doctors at the GRS clinic in Montreal have an excellent website which has a Flash-based function that details the procedures that they perform. For other surgeons around the world, check out the TS Surgery Guide.
Currently, the Saskatchewan Government only funds a fraction (about 30-40%) of the total cost of Gender Reassignment Surgery ($20,000) resulting in a huge financial barrier for many people. If you have started transition with the aim toward surgery, or if you are affected in any way by the government's lack of full funding, you might wish to consider filing a Human Rights Complaint.
Changes after bottom surgery always depend on the procedure used, and the individual's ability to recover. The older a person is, the less resilient they are, and the more difficulties there can be with nerve endings restructuring in the area. In most cases, surgeons prefer that a patient has not undergone orchidectomy (removal of the scrotum) at an earlier time, as some of this tissue is also needed. Results are usually very good and quite believable, as the surgery is quite well-developed for trans women. After surgery, a few months of dilating exercises and aftercare are required before the equipment is ready to test-drive.
Aftercare
During GRS, the vaginal canal is created using the existing skin, formed over a tube and sutured in. Regular dilation is required to keep the canal open and as deep as possible. Dilation involves the insertion of different-sized surgical stents, and in the months following surgery, it can be quite frequent (i.e. 3 or 4 times a day for up to an hour each time, during the first month). The routine becomes less demanding over time, as the canal heals, but it is crucial to follow, or the canal could collapse and harden -- and once that depth is lost, it cannot be regained even with surgery.
Legal Name Change -- In Saskatchewan, you can apply for a legal name change at eHealth (2130 11th Avenue, Regina, Saskatchewan S4P 0J5; 1-800-667-7551). All the information you will need can be found on their website.
Once you receive your Legal Name Change certificate and reissued Birth Certificate, you can also update the following:
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Saskatchewan Health Services Card. This can be done at eHealth (2130 11th Avenue, Regina, Saskatchewan S4P 0J5; 1-800-667-7551) or online via their website.
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Driver's License. This can be done at any SGI Motor License Issuer. You will require your Certificate of Name Change and other proof of identity documents.
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Social Insurance Number. This can be done at any Service Canada location. You will require your Certificate of Name Change and other proof of identity documents.
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If you are a landed immigrant, Immigration records are never changed following a name change (to prove your legal name for identification purposes, you will need to provide your immigration papers along with your Change of Name Certificate). To obtain Citizenship documents showing the new name, contact the Canadian Citizenship office for more information.
Changing the Gender Marker on Your I.D. In the case of most of the above identification, the gender marker ("M" or "F") will not change, until you can present a letter from your surgeon that Gender Reassignment Surgery (GRS) has been completed. This leaves non-operative transsexuals in an unfortunate situation, and some activist groups are working toward gender recognition for those who have lived as their preferred gender for some defined amount of time. You might wish to consider filing a Human Rights Complaint.
Dating And Relating To A Lover Or Potential Partner:
Dating Strangers... Safely
Dating can be dangerous, especially with transwomen dating straight men or men who are not yet fully comfortable with their sexuality (and this is not always visible in the beginning). This can be complicated moreso by "Tranny Chasers," who will often either be fetishists of a sort who will view you as not much more than a novelty sex toy, or else questioning men who might just as easily play with you, then turn around and blame you for their guilty feelings... and possibly take it out on you physically or emotionally. First impressions are never enough, as some questioning men may be completely believing their own words when they express their affection for you -- and therefore not betray their hidden prejudices and guilt, because those things are completely submerged during the conversation.
In the BDSM community, a concept was developed which is perfect for transwomen who are going on blind dates -- especially with men who know they are trans -- although it requires the assistance of a friend who can be trusted completely. It is often called the "silent alarm," and there are several variations... you can settle on what is most comfortable for you.
As preliminaries, for your first meeting, always insist on a public place. A restaurant or a mall coffee shop is ideal. Never agree to meet a stranger in a private place such as a hotel room or home. Make sure that your transportation to and from your first meeting is under your control -- don't rely on your date for a ride home. And don't let someone know your home address until you're comfortable with them first.
A "silent alarm" is a situation in which you tell your trusted friend where you are going, and when you expect to be back; you also give him or her any information that you may have about the person you will be seeing. You arrange with that friend to call them at a prearranged time, no matter what the events of the evening bring. If you don't check in, your friend is to call the local authorities immediately, with any information they have. It's also a good idea to prearrange with this friend to have an "unsafeword" or phrase that you might include in conversation, in the event that you are forced to make the call under duress, and need to indicate that you need help, without arousing suspicion from a person threatening you.
Helpful points:
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If you have your date's phone number, try to arrange to call it first, to verify that it is correct.
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Inform your friend beforehand what your plans for the evening are: time, place, etc. If anything changes, let them know during a check-in call.
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Don't use your date's phone or cell, in order to help avoid the call being traced later, thereby potentially putting your friend in danger.
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The "silent alarm" is most useful as a deterrent. If he knows that you need to check in with a friend, he'll know that if he harms you, this will alert someone else.
This all sounds paranoid, of course, but when it comes to blind dates, people met online and the like, there is virtue to it. You can, of course, modify the procedure to suit your situation, and if you feel that a more relaxed system of simply passing your date's name and number on to your friend and arranging to call them whenever the date is over will suffice, then do that. But any Plan B is better than nothing.
"When Do You Tell Him/Her?"
The question is first one of IF you need to tell a partner that you've transitioned (or are transitioning) from the opposite gender. People will often have strong viewpoints on either side of this. It's basically an issue of whether you want to 1) tell someone you're interested in now and risk having them run away without ever getting to know you, 2) tell them later and risk having them leave despite all the care and emotion you've invested in the relationship, or 3) never tell them and risk having them find out another way, making them feel often quite betrayed and angry. And honestly, none of the three are particularily appealing. In all cases, the reaction from a potential partner can often be a strong one -- it can even lead to violence.
Although there is the sense of bravado that says "if he (or she) doesn't like it, then it's better not knowing him (or her)," but the truth is that rejection always hurts regardless. What's more, once you're out to someone, your origins in the other gender may become a recurring point of contention in the relationship -- it may be thrown in your face frequently, or your partner may start seeking out your male traits (physical, personality, etc.) and find fault with them, whereas he or she might have remained otherwise oblivious. If this doesn't happen, then at the very least there is still the risk that in your partner's eyes, you might cease to be "the cute girl who likes club music and visiting the art galleries" and become just "the transsexual" -- as if there are no other interesting facets about you beyond that point. This can especially be a problem in that we as trans women are psychologically female (or at least mostly so), but the stigma of being "transsexual" can often make others think of you more as "male" or "ex-male," than "female." To others, the word "transsexual" may also often conjure the image of drag queens, pornographic "she-males" or misguided gay men, and connotations from those things that may not have the least bit of relevance in your life -- but these things might become the standards with which you become measured.
Everyone's choice is different and valid. There is no shame in hiding a transgendered past -- however, this can lead to the same sense of living behind a mask as the one that drove you to transition in the first place. Also, if your partner can tell that you're hiding elements of your past (i.e. "why don't you have any childhood photos?"), this can sow distrust in the relationship.
IF your partner is ultimately going to find out, either because of the way you pass or because his or her life overlaps your old male life in any way, or for any other reason, earlier is undoubtedly better -- there is always a far greater feeling of betrayal if it is felt that a truth has been hidden for a longer period of time. It is also a good idea that this disclosure should come before any physical intimacy is shared -- intimacy with a transsexual will often raise a lot of questions with people about their own sexuality, and these questions become more a thing of panic if intimacy has already been shared. But it is not necessary to tell someone on day one. You can get to know the person, give them the opportunity to discover what they like about you, and give things the chance to "click." Sometimes, the key to your partner accepting you depends on how badly he or she wants to accept you. And if this person does not know you at all, there is no reason for them to not walk away.
If you decide to tell, it's best to set aside a time, collect your thoughts, and make it special and comfortable for both of you. Let them know how much you value the partnership, and that you want to share something very personal, that you rarely share with anyone else (if, of course, it's true that you rarely tell anyone else). And if your partner sees himself as strictly straight or sees herself as strictly lesbian, be prepared for this person to need some time to reassess things.
And at that point, all that can be said is, "good luck...."