My years of providing therapy to transgender clients has taught me as much as I’ve taught them. Moreover, I’ve seen the changes to medical-field rules and practices for transition care.
My first transgender client, Male To Female, or MTF, came to me ten years ago. Jessica L. was and is a joy and an inspiration. I had some information on transgender transitioning, having worked in a practice with an M.D. who was herself transitioning. I also remember becoming intrigued and an ally of the process decades ago, reading about transgender people in Sweden when I was a teen.
But it took Jessica L,. as my first transgender client, to take me on the journey to greater understanding. I learned as much from her as she learned from me.
Since then, I continue to work with her on issues not related to transitioning, such as career, education, communication, anxiety, and relationships. I’ve worked with her and others in all stages of transitioning on the issues surrounding transition, but with all their other issues as well.
However, if you’re just starting out, here are the steps most people working in the field of transitioning recommend.
- Therapy can help at every stage of transition. When people come to me for help in deciding when, whether, and how to transition, I like to begin with a discussion of when they first became aware they felt different from the gender they were assigned, and what began the process of considering transitioning. This is in order for us both to be clear on the strength of desire to transition and the timeline they want. Most, of course, come to me very clear on the need and desire, and are ready. Some younger clients, ages eleven to fifteen, are just starting to question their gender identity, and this helps them make the decision. Some decide to transition, but some decide to wait. They may be receiving push back at home, and need a safe place to discover more about themselves. For many, it’s the first time anyone has listened to their journey without judgement.
- Some endocrinologists and other doctors who prescribe hormone blockers or hormone replacement therapy (HRT) want a letter from a therapist who’s worked with their patient for at least three months. This isn’t standard across all doctors, and now is considered more of suggestion. Some doctors will recommend therapy for emotional and mental support during the transition process. Some cities have low-cost centers where you can access both therapists and doctors who prescribe hormone treatment.
- Living as the preferred gender for a certain length of time, usually a year, is also something that doctors used to want before prescribing hormones. This too has now become more of a suggestion than a mandate. Presumably this was for the transitioning person to experience being their preferred gender before starting hormones. Hormones create changes, that after a certain time, are irreversible. However, living as another gender before hormones and/or surgery can be quite difficult after puberty, and even dangerous in some places. This is best left up to individual choice. You might want to pursue some activities as the preferred gender if you don’t feel safe enough to come out completely before hormone therapy and surgery.
- Advocate for yourself with doctors. The growth of advocacy among transgender people is why the outdated models of requirements to be allowed to get hormones have changed. Current thought, supported by WPATH, World Professional Association for Transgender Health, is that those seeking hormone therapy should be able to get it without medical and psychological gatekeepers. As a therapist, I agree.
- At some point, you’ll likely want to officially change your name from the name given to you at birth to the one you’ve chosen and want others to use. A name change generally requires a judge, and there is a cost, usually around $300. One of my clients spent $1,200 for both name and gender-marker change, and didn’t have to see a judge because they went through their lawyer. Once name and gender, the court will give you a letter to get a new birth certificate, which you can use to get a new social security card and driver’s license. These are necessary for many things, including traveling, getting jobs, and getting health insurance in your new name. While you can get a job where you ask them to use your new name, they may require a copy of your driver’s license, which can lead to issues as simple and as fraught as which bathroom to use if you haven’t changed your name and gender on your license.
- Surgery is a particularly personal subject and choice. For Female to Male (FTM) Some people choose both top and bottom surgery. Some prefer removing the breasts, but don’t feel the need for an artificial penis, as the clitoris usually enlarges with testosterone treatment. Since the clitoris and the penis have similar nerve endings, this can work quite well.
- Surgery for Male to Female (MTF) transitioning may involve a lot of decisions. I’ve separated this into two broad sections: top surgery and bottom surgery. Some transgender women choose get breast implants, but breasts will grow on their own with estrogen therapy and testosterone blocker. If you’re satisfied with your natural breasts, then you may opt not to enhance them. If you prefer them larger, implants are an option.
- Some choose to create a vagina using penile skin. It’s a fairly arduous process involving stretching the tissue after the surgery, but for those who feel a vagina adds to the authenticity of the transition, it can be a good option. My friend and screenwriter colleague Rachel Stevens. writes “in depth” about the experience in her funny and revealing book “Blowing Up Rachel,” available through Amazon books.
- Some trans women choose to have an orchidectomy, a removal of the testes. Since the penis often shrinks as testosterone is blocked, some choose to think of it as an enlarged clitoris, and decide to keep it. My original transgender client refers to hers as her “birth defect.”
- A final note on therapy. Some transgender people hope or believe that transitioning will “cure” their depression or anxiety, if they suffer from these conditions. I’ve definitely seen improvement in mood in my clients who transition. However, if there are other causes, including genetic brain chemistry, that cause depression and anxiety, they should be treated as separate from the transitioning process. Research indicates the best results for depression are a combination of therapy and medication.
These are some of the basics of transitioning. There’s more to the journey, that I will detail in later articles. If you are among my transgender followers or readers, Emma Holiday , Pierre Trudel ,
theoaknotes , WeeziSbaby , please feel free to add information in your comments, or email me directly to suggest additions, topics, or revisions.
This post was previously published on medium.com.
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