If you've been diagnosed with Gender Dysphoria (as I was in August 2001) the obvious question is "what can I do about it?"
Sadly, there's no simple answer. What works for one person may be disastrous for another. One thing's for certain - the more information you have available, the more informed a choice you can make.
When I started out on this long road in 2001 I tried hard to learn everything I could so I knew exactly what I was getting into, particularly from a medical perspective.
I hope to share some of that here. I'll start with an overview of the process from a medical perspective, followed by the implications (as I understand them) of the two different treatment regimes available in the UK - NHS or Privately Funded.
Finally, I'll describe the specific details of my transition and treatment.
The process of changing role in society (in my case from Male to Female, but the reverse also applies) is known as Transition.
The definition's a bit blurry, but it effectively starts when you start preparing for the change (which could be well in advance of starting treatment), and ends when you publicly change your name and role. My transition effectively started in March 2002 when I started facial hair removal (more on that later), and will end in late December 2002 when I change role.
I won't kid you here - it's a very difficult thing to do, and expect a lot of heartache along the
way. Although I've been lucky in that my build and appearance works in my favour, I know others without
these advantages who've also transitioned without problems.
The medical treatment of a Male to Female (MtF) transsexual woman (transwoman) involves the following:
Although the details vary hugely from individual to individual, there is sufficient commonality
that an individual can have a fairly good idea of her path through transition, and what is likely to
be required for her to succeed. I'm certainly no exception in that regard!
Hormone Replacement Therapy
MtF transsexual patients are usually prescribed female hormones from early in the transition process. If necessary, an anti-androgen may also be prescribed to suppress the effects of male hormones (which are still in the body prior to surgery).
Female hormones affect the body in numerous subtle ways:
Unfortunately, hormones will not affect bone structure (although the bones can shrink a little - expect your feet in particular to get a bit smaller!), or the size of the voicebox.
When a patient has been on hormone therapy for several months and her appearance has changed sufficiently, a full-time change in gender role becomes possible. At this point, a “Real Life Test” (which will be described shortly) begins.
It is worthy of note that even after surgery, transsexuals must continue to take hormones since
their own bodies will not produce them in the correct amount or balance to maintain their health.
As previously mentioned, female hormones do not have any observable effect upon facial hair growth in MtF transsexuals, and therefore it must be removed in some manner for transition to be practical.
Although short term hair removal methods (through methods such as plucking, waxing etc.) may be practical for some in the short term, a long term solution must inevitably be found. The two methods available at present are electrolysis and laser hair removal.
Both techniques rely on causing damage to the root of hair cells, thus retarding or stopping hair growth.
Electrolysis achieves this by applying a measured electric charge via a needle inserted into each follicle in turn. Since each follicle must be treated individually, treatment can take a very long period of time (it is not uncommon for facial hair removal by electrolysis to take several years in total).
A further problem is that for treatment to be effective, significant hair growth must be present (at least 2 days, depending on the growth rate) which is obviously a major problem for anyone presenting as female.
Laser hair removal is a newer technique, in which a measured pulse of laser energy is applied to a small area, causing thermal shock to the hair follicles in that area.
In order to transmit the laser energy to the hair follicles rather than the skin (which would cause burns), the wavelength of the laser used is selected to match the absorption frequency of melanin present in the hair follicles. As a result, this technique is only suitable for individuals with dark hair and fair skin.
Although the long term results are not yet proven, laser treatment is much faster than electrolysis
due to its speed and the minimal hair growth which must be present for treatment to be successful.
Vocal Training and Speech Therapy
Like facial hair removal, voice training is absolutely essential in order to transition successfully. However, unlike hair removal a degree of voice training can be undertaken by an individual without outside assistance, although formal speech therapy may be beneficial or required – it really depends upon the individual.
In some cases, vocal surgery is undertaken. Since the techniques involved are very new and the results
not predictable, most patients generally try to avoid vocal surgery if at all possible.
Real Life Test
Before being accepted for GRS/SRS surgery (see below), a transsexual patient must undertake a “Real Life Test”, during which they live completely in the desired gender role for a period of at least a year.
During this period the patient will be, to all intents and purposes, female. Throughout, her progress is monitored by their doctor and psychiatrist, and assuming it is completed successfully and the patient is confirmed to be physically suitable, a letter will be issued certifying that the patient is a suitable candidate for surgery.
Among private patients the Real Life Test commonly starts after several months of Hormone Replacement
Therapy. I started on Christmas Day 2002 - just under 7 months after starting HRT.
Genital or Sex Reassignment Surgery (often referred to as GRS or SRS) is the final – and irreversible – part of the treatment process.
By the time a patient has been accepted for surgery, she must have been living full time “in role” in the community for (according to the Harry Benjamin Standards of Care) at least a year, and have demonstrated her suitability as a candidate for such a major step.
In practice the RLT period is usually significantly longer: patients undergoing NHS treatment have to contend with long waiting lists due to the high demand and small number of NHS surgeons qualified to perform GRS, whilst private patients must save up to pay for the costs of surgery.
In order to further soften the facial appearance, and improve their ability to be accepted by society, patients may also undergo Facial Feminisation Surgery (FFS). FFS surgery typically involves the reduction of the size of the eyebrow ridges, chin/jawline and nose. The results can have an enormously beneficial effect on the self-esteem of the patient and therefore her ability to fully function in her new role.
GRS/SRS and FFS surgery may be undertaken simultaneously in some cases. Depending on the techniques
used, recovery after FFS is normally fairly quick, but GRS/SRS surgery can require a long recovery
time (between 6 months and a year to heal full) and a significant time off work (8-12 weeks is commonplace).
NHS and Private Treatment
There are two roads through transition in the UK – via the NHS or privately. From the perspective of the patient, the treatment regime followed in the two cases is significantly different – as will be seen in the following sections.
If you opt for NHS Treatment, funding varies considerably between Primary Care Trusts. In the past, some would provide funds for psychiatric counselling, but not for treatment. This is now illegal. All PCTs must provide treatment, although they may impose unreasonably low quotas or insist patients follow a specific treatment regime. It's a bit of a mess, quite frankly.
As far as I am aware, one essential treatment – facial hair removal - is not generally available on the NHS, so this must be paid for by the patient regardless of whether she transitions under NHS care or privately (this is especially crazy when you consider that next to surgery it's the most expensive part of the treatment!).
Furthermore, the NHS Gender Clinics themselves have long waiting lists, which often results in the transition taking a greatly extended period of time. Possibly as a result of the volume of demand, NHS Gender Clinics are now requiring patients to undergo a Real-Life-Test before receiving hormone therapy, which obviously makes it much more difficult for the patient to be accepted by society.
As a result of these problems, many patients (myself included) attempt to fund their transition privately. Unlike the NHS regime (which seems to be rigidly structured), private treatment places more of the responsibility for her progress through transition on the patient. Hormone therapy is usually started within three months of the first consultation with a consultant psychiatrist, and the Real-Life-Test typically starts several months later.
If the patient copes well with the Real-Life-Test, approval for surgery is likely to follow a year
or so after it was started. Since the costs of surgery must be met by the patient herself, in many
cases patients will not seek surgery as soon as approval is given - a two year period from the start
of RLT seems to be fairly typical.
My Own Transition and Treatment
Since my skin and hair colour is suitable for treatment by Laser Hair Removal, I initially opted to use this technique in preference to the much slower method of electrolysis. From March 2002, each month I visited Christianos Laser clinic in London, with each treatment taking up to 50 minutes including preparation, and costing £220.
Unfortunately, my facial hair proved to be pretty resistant - I had 16 treatments before switching to electrolysis in October 2003 to deal with the remaining hairs. Since hair removal by electrolysis is much more commonly available than laser treatment, I was able to have treatment locally (which costs £30 per hour) rather than travel into London, which of course has made things easier.
I've also had chest and abdominal hair removed by the laser, this time by Hairaway (now Lasercare) in Shaftesbury Avenue, London. A full treatment cost me £140, and needs to be done every 8 weeks or so. After six treatments of my chest and five on my abdomen, I'm now largely clear.
Prior to my reassignment surgery I also had two sessions of hair removal on my bikini and genital
area. I expect to need another three or so before the areas I want treated are clear, but I'm waiting
until I heal a bit more before restarting treatment!
Hormone Replacement Therapy (HRT)
I started hormone therapy under the care of Russell Reid (of the London Institute) at the end of May 2002. At the moment I'm being prescribed the following:
I'm glad to say that I've not noticed any side effects (other than increased appetite), and my figure is everything I ever wanted it to be!
This prescription costs around £182.50 for a 3 month supply, or around £60.83 a month. Fortunately, my Primary Care Trust is now paying for it, even though it's a private prescription! If you're undergoing treatment and having problems persuading your GP to enter into "Shared Care" arrangements with a private psychiatrist (Russell Reid is the most well known one in the UK) I strongly recommend having a chat with your local Patient Advice Liaison Service about the subject.
You may (as I was) be pleasantly surprised at the outcome!
Vocal Training and Speech Therapy
I've not undertaken any formal Speech Therapy so far. Instead, I researched the techniques involved, ordered a voice training CD and started practicing (by singing in the car while driving to and from work!), with quite reasonable results.
Based upon what I have learnt so far, I'm sure I can achieve the results I need to be accepted by
society without any form of vocal surgery. Right now, my singing voice is much more convincing than
my speaking voice, but once I've been full-time for a while that should sort itself out.
Real Life Test (RLT)
When I moved out of the family home at the end of October 2002 I changed my role "part-time" - which effectively meant presenting as female at weekends and in the evening if I was going out. Over time, my confidence improved immensely - I no longer felt self-conscious or anxious by the time I transitioned
For some time beforehand I'd been buying clothes and learning makeup skills, which gave me time to make and recover from the inevitable mistakes along the way, and increase my confidence in my ability to survive the experience and rebuild my life.
I officially started my Real Life Test on Christmas Day 2002, and I'm glad to say that I didn't
encounter any major problems. The problems I did have were emotional in nature rather than to
do with others perception of me...I "pass" fairly well and have not faced any hostility.
The fact that my appearance and mannerisms have now changed to such a extent that the transition appeared
so natural probably helped a great deal in that.
The results are everything I ever dreamed of, and I'm now looking forward to the rest of my life.