Saturday, November 26, 2005


A friend of ours divulged to us the other night that he is undergoing a transformation from living as a biological man to living as a woman by choice. He is assuming a female name, dressing as a woman, and embracing a feminine identity that he has felt near and dear to his heart since he was very young. This incredible conversation sparked my desire to write about my work with transgendered clients, something I have yet to address here on DD.

My friend's private journey aside, I have had the pleasure to have a number of transgendered patients over the years and it's developed into one of my keen professional interests. Having always considered myself a gay/lesbian/bisexual ally, my close work with the transgendered has led me to embrace the role as transgender ally as well. In my current job, I have had one patient who was a female-to-male (FTM) transgendered individual, and I currently have two MTF patients with whom I am very close. Their experiences inform my current (limited) knowledge base.

Last November, at a conference of the Association of Nurses in AIDS Care (ANAC), my eyes were opened wider than ever by Sam Lurie, the speaker who delivered the Plenary Address on Transgendered Health Care. Sam's approach to trans healthcare entertains, educates, and advocates on a variety of levels, and since that conference my interest has been duly piqued.

When thinking about this issue, the average person makes assumptions, remembers the "trans-sexual" label which seemed to be so popular in the 70's, and images of trans stereotypes may cometo mind. I have vague memories of a famous football player who underwent gender reassignment surgery when I was a kid, and somehow that image became confused with another memory: Joe Namath, another football star, doing a commercial for men's panty hose. But I digress.

Thanks in large part, I think, to the success and political acumen of the women's rights, civil rights, gay rights, and AIDS rights movements, the transgendered community has gained political power, entered the mainstream consciousness, joined forces with the Gay, Lesbian, and Bisexual communities, and forced society to gaze deeply at its definitions of gender. Now for some, this may be such a stretch as to snap the cognitive rubber-band, figuratively speaking, when taken in context with the current culture wars over the definition of marriage. But be that as it may, issues of gender and gender identity are and will continue to be part of the cultural zeitgeist and call for our (divided or undivided) attention.

That said, from the point of view of a healthcare provider who wants to be "trans-friendly", the germaine issues are many. First of all, one must become familiar with the nomenclature of the trans community in all its form and derivations: FTM, MTF, trans-man, trans-woman, op, non-op, and the list goes on, many terms being used within the trans community itself which I would not use in my own conversations. (This is similar to how the African-American and gay communities have re-adopted terms that were previously used as derogatory in the wider culture, breathing new life into those terms for the purpose of empowerment and self-definition.)
The health issues which a transgendered person faces are many. Contrary to popular opinion, there are many people who define themselves as trans who have not had---and will never have--- gender reassignment surgery. Perhaps there are economic barriers to such a radical transition, or perhaps the person is comfortable with their biological genitalia and simply prefers to "present" as the other gender. This is sometimes referred, as I have learned, to being "Op" or "Non-Op", and I have also seen the term "Pre-Op", meaning someone who is preparing for surgery, although that preparation may last a lifetime and never actually occur.

Surgery aside, many FTMs and MTFs will choose to undergo hormone therapy, a course which will cause physical, physiological, and even emotional changes for the individual. If a man takes "feminizing hormones", he will grow less facial and body hair, develop a softer voice, softer curves, and lose muscle tone, gaining fat in the hips and more of the familiar "hour-glass" shape of a female body. A woman taking testosterone will find her voice deepening, facial hair growing in, and muscular growth occuring. Both of these groups will find, aside from physical changes, documented alterations in thinking and communicating styles, lending credence to the theory that gender is widely dictated by hormone levels which can be altered and adjusted based on the way in which the individual wishes to present to the world and and be perceived by the world.

Hormone therapy presents challenges to the healthcare provider, both in its execution and monitoring. While there are protocols for such therapy available to the curious and conscientious provider, many doctors might feel uncomfortable with such "off-label" usage and decline to be involved. Not covered by any insurance, cost and availability become factors, and the quality of hormones obtained through the black market could be questionable, as well. Off-label or not, patients need expert guidance, compassionate care, professional oversight, and an unbiased advocate.

Picture this: you are a woman who has always felt that your true identity was male despite the genitalia with which you were born. You decide as a young adult to undergo hormone replacement therapy, knowing that it is most powerful and effective before a person is in their twenties. You grow facial hair, hair on your legs, arms and chest, your muscles develop, your voice deepens, and you are able to go out in the world and "pass" as a man.

There are several complicating factors in our scenario, however. Perhaps you would like gender reassignment surgery but it is an economic impossibility for you, or perhaps it is not even a question and you're happy with your current body vis-a-vis hormone replacement. Being biologically female, you must undergo a pelvic exam and PAP smear every year, an exercise which tests all of your abilities to advocate for yourself and educate others about your healthcare needs. When you enter the health center, you are seen as a man and there is no doubt as to your gender. However, when you get to the front desk, you need to communicate to the receptionist that you are there to see the gynecologist. How does she or he react? Do they ask why, as a man, you need to see the gyn? Do they verbally abuse you for being a freak? Do they "out" you in front of the other patients standing in line? When they realize you are trans, do they loudly ask, "SO, DID YOU HAVE 'THE OPERATION' YET?" (This would be akin to me walking up to a patient in the waiting room and asking if I could see their genitals!) How many of these trials and tribulations will you endure for the sake of your health? How will you decide which rest room to use? How many dirty looks can you entertain? How much of this stress is worth it?

Once you make it into the exam room, the next challenge is the medical assistant. Will you need to explain again that, yes, you look like a man, but yes, you have a vagina and need a PAP smear? Will you overhear the medical assistant giggling with her colleagues in the nurses' station? How will the gynecologist react when she walks in the room? Will she be understanding? Repulsed? Judgemental? Refuse to examine you? Maybe this will be your last pelvic exam for the next ten or fifteen years. Avoidance of such traumatic experiences might be understandable, but could have grave and perhaps fatal consequences.

As you can see, most of us would never even consider such scenarios, let alone think about how to assuage fears and change insitutional policies which discriminate against the transgendered community. As a healthcare provider in a world of fixed gender definitions and rigidly held beliefs and stereotypes, advocating for patients on this level can be an uphill battle on the institutional and cultural level. But having seen the pain and confusion which such experiences can cause, I am on the side of advocating, fighting, and pushing for equality and healthcare parity for a population whose needs are many, and who are, whether our culture accepts it or not, here to stay.
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