Image:  Odawara Sajawagara

Tis the season for resolutions.  I made three this year.  The first two–“turn off the light, close the pantry door” and “use nicer words”–require neither cajoling on my part, nor cooperation on the part of anyone else.  I will either succeed or fail entirely based on my own efforts.  The third is a horse of a different color.  I resolve to be consistently recognized as female in my most meaningful social interactions.

Those of you who have read this blog from the beginning may see this as a shift on my part.  I had, after all, said that my identity was stuck somewhere in the middle (but to the feminine side) of the binary spectrum of gender.  This remains true, of course largely due to factors well beyond my control (physical attributes, how I was socialized, etc).  Further, my conviction that future society must see gender as less “either/or” and tolerate broader ranges of self-expression remains unshaken.  Nevertheless, my sanity here and now requires that I find a way to navigate the awkward landscape of gender variance in a society that has not yet made these adjustments.  I have found, through years of ongoing experience, that staking out a spot near the center of the gender spectrum is uncomfortable and difficult–too difficult–for me.  Besides, the more permission I feel to explore my identity, the more toward the feminine side of the spectrum I seem to gravitate naturally.  Androgyny is a legitimate choice, but it is not mine.

Which brings me back to the resolution.  Despite explicit statements that I identify female and prefer feminine pronouns, I continue to be subjected to an incessant, daily barrage of masculine pronouns, “good sirs” and other increasingly ridiculous displays of insensitivity, poor perception and in some cases, not-so-passive aggression.  To some degree, I initially brought failure on myself by grossly underestimating the time it would take people to adjust and remember.¹ Eighteen months after stating my preferences, though, I think it is reasonable to ask for and expect proper address.

Still, some still urge me to be patient.  Other women sometimes mention that they occasionally get called “sir”, as if to reassure me that they know how I feel.  Here’s the difference.  If someone calls another woman sir and the error is pointed out or realized, the person who made the mistake immediately feels foolish.  When someone calls me sir and I explain that this is not correct, I am the one generally taken for a fool.  It is hardly an isolated experience.  The first few on any given day I can generally handle, but the cumulative effect of dozens of incidents every day is like being slowly pecked to death.

I get the need for patience when people cannot see my face or have never met me (or another trans person) before.  The poor soul on the other end of the phone arrives at a gender judgment subconsciously.  The interaction still causes me discomfort, but does not provoke me to assign any blame.  If I would be free of these mis-assignments, I will need to climb the high mountain of vocal change.  I have been thinking long and hard on this decision, and currently lean rather strongly toward starting the effort.

Being mis-pronouned by a stranger, however, is not what this post is fundamentally about.  Nor is it about the person who means well and has made demonstrable effort, but occasionally makes a mistake, often catching it quickly afterwards.  These things I can deal with².  What wears me to the bone are closer contacts who are no more likely to address me correctly now than they were a year and a half ago, and particularly those who, if corrected, act like I am being unreasonable or pushy.

Well, so be it. I resolve to correct anyway, toward the end of experiencing a daily coherence that 99% of the population takes entirely for granted.

This may prove challenging in my professional life.   Up until now, I have never once corrected a patient or visitor on the way they address me.  I reasoned that they arrived to my workplace with weightier matters on their minds, and that I had no right to impose further upon them.   Positive motives drove this choice, but in making it, I accepted something that I now realize I should not–that my personal dignity is to be regularly sacrificed for some sort of public good.  I’ll be honest, I’m not sure how I will take on the task of informing my clients respectfully that my pronouns are feminine.  It will take some planning and practice on my part, and I am certain I will screw it up until I find a way of communicating my identity that neither offends nor detracts from the business at hand.

As I said, I can not achieve the goal of being properly pronouned through individual effort.  I recognize that by making this resolution I am calling for others to do some heavy lifting.  To be sure, they may decline, and  I can’t force them to get it right.  I can, however, decide to eliminate potentially toxic relationships from my life.  And I will.  Yes, it really is that important to me.

I imagine that many kind hearted souls might be reading this and flogging themselves for having made pronoun mistakes along the way.  Please don’t.  Things like this really do take time.  I am just now drawing a line in the sand and asserting that I have the right to expect more going forward.  Most of you have tried so very hard, and I genuinely thank you from the bottom of my heart.

May I offer you some help though?  Trying to remember to do something that conflicts strongly with what you still think deep down doesn’t work.  The deep stuff always bubbles to the surface.  The primary change needs to happen down below.  Accept me as female, and the pronouns fall in line effortlessly.  To the extent that you mentally file me away as any version of “man posing as woman”, you will forever trip over the words.³  Change that and you will never make a hurtful mistake again.  It’s hard, and I can’t make you do it, but I hope you will.

Happy New Year to you all, and thank you again for taking the time to read.

(Image credit:  Edvard Munch, Melancholy)

Seat belts on, good people.  This is a long and admittedly contentious post.  If you still wish to proceed but want to skip the History McNugget, feel free to jump down to here.  I’ll also point out a nice spot lower down where you can bail out well before the bottom of this soon-to-be classic.

**inhale**

Pressed to recall the name of an ancient physician, most people will come up with Hippocrates or perhaps Asclepius.  The former we remember for the oath bearing his name, wherein doctors promise to “first, do no harm”.  The latter was a mythological figure, son of Apollo, taught the healing arts by centaurs and so skilled in his craft that he learned to bring people back from the dead.¹  In terms of historical influence, however, none surpass Claudius Galenus or simply, Galen (b. CE 127; d.circa CE 200).  A skilled anatomist, Galen moved medicine forward in a huge way, moving the seat of consciousness from the heart to the head, describing the double loop of the human circulatory system, demonstrating the bellows-like function of the ribcage and diaphragm, and pioneering several promising surgical techniques.  So influential was he that medicines were referred to as “galenicals”, and his writings formed the basis for medical education for 1600 years.

In fact, such reverence turned out to be a major problem.  The persistence of his teachings was not so much due not to their finality or accuracy, but rather to the intellectual paralysis of Christendom throughout medieval times, when veneration for tradition and dogma were seen to be the shortest road to knowledge.  To question Galen’s authority–as he, an inquisitive scientist, would have done–was widely considered medical heresy until roughly 1800.

Relics of Galenism persist in our language to this day.  As did Hippocrates before him, Galen believed that fluctuations of mood were caused by excesses of the “four  humors”–blood, bile, phlegm and black bile.  Healthy was the body in which these fluids balanced, but if they did not, one was said to be a person of ill humor.  Each particular type of imbalance resulted in a certain temperament, sanguine (blood), choleric (bile), phlegmatic and, as represented by Munch’s painting, above, melancholic (black bile).

I propose that the moral of this story is that the tradition of misinterpretation and mischaracterization of mental health issues in Western medicine runs very long and deep indeed.  “Humorism” is  only one bizarre example, paling in my opinion to hysteria (from the Greek hyster; uterus) a condition believed to be caused by the abnormal movements of the unsatisfied (i.e. not enough sex and childbirth) uterus in the woman’s body.  Next time someone tells you that you are being hysterical, feel free to answer either, “You must be mistaken…I don’t have a uterus,” or “Actually, I’m almost certain my uterus is in its proper anatomic position.”

**exhale**

Today I would like to delve into a more contemporary example of rampant pseudoscientific speculation–the phenomenon of transgender regret.  The general idea is that a) transgender people frequently experience disappointment following medical/surgical transition; b) remorse drives transgender people to despair, leading to complicated medical detransition², depression and/or suicide; and that c) the media conspire to hide this fact from the public.

Let the good folks at Fox News be “Fair and Balanced”.  I have no intention of cloaking my belief that transgender regret is at best a specious medical myth, and at worst a deliberately deceptive smokescreen propagated largely by transphobic zealots in order to shame or frighten transgender people from seeking medical attention.  Nevertheless, I will charitably take upon myself if not the burden of proof, at least the full duty of persuasion.  I intend to demonstrate that transgender regret as it is depicted is, to quote one of my favorite nurses, “not even a thing.”

As with many conspiracy theories, there is no shortage of proponents, in this case reverberating like internet lighthouses about the treacherous rocks of gender transition and the looming fog of fawning media and a profit-seeking medical establishment.  Nevertheless, the movement has a patron saint, Walt Heyer, aka “the man who has had two sex changes”.  Walt lived as male until age 42, then transitioned medically (hormones) and surgically (SRS³), taking on the name Laura Jensen.  Initially, all seemed to be well, but the further he got from the surgery, the more disillusioned he became.  He eventually concluded that he had made a horrible mistake, and that his cross gender feelings were the result of childhood trauma, including sexual abuse.  Eight years later, he renounced his transition and re-asserted himself as Walt.  Since that time, he has become a tireless voice cautioning against gender transition.  Now in his mid-seventies, he contributes to frequently to conservative media and blogs at http://www.sexchangeregret.com.

As too often happens in areas of controversy, transgender advocates and allies often see ad hominem attacks on Mr. Heyer as the most efficient way of destroying his arguments.  I reject that route.  I am fiercely protective of my own prerogative to tell my story, and no less so of Heyer’s to tell his.  I take his word for it that his transgender feelings were no less genuine than mine, and certainly real enough to him at the time.  Neither will I dispute his current conviction, that what he thought was gender dysphoria was actually fallout from childhood psychological trauma.  If he says that he feels happier and whole having de-transitioned, I have no reason to doubt him.  And finally, I assert that he has as good of a claim to the use of internet bandwidth as I do.  Echoing Evelyn Beatrice Hall, I disapprove of what he says, but I will defend to the death⁴ his right to say it.

In short, I have no quibbles whatsoever with the biographical reflections of Walt Heyer, or even to his assertion that some transsexuals eventually de-transition or even commit suicide.  Some clearly do.  My beef is with a larger movement which overstates risks and trivializes benefit of generally effective therapies, piles shame and disinformation on already vulnerable people, and which, despite increasingly savvy packaging, can barely disguise its roots in religious fervor and/or transphobic bigotry.

Before going further, let me summarize what we know about the efficacy of medical transition a this point.  First, somewhere northwards of 90% of patients who have had SRS report being happy that they did.  Less well understood is whether they are are objectively better off post-transition.  One study, for example, reported that 90% of patients were satisfied or very satisfied with SRS, but a less rosy 66% stated that they were “satisfied with life as it is now.”  It would be interesting to know how non-transgender people with no experience of SRS would respond to that second question, which to my eye appears substantially more profound and complex.  Another study places post-operative satisfaction at 95%, with  dissatisfaction being related to quality of results rather than recantation of their new gender assignment, but only 62% of these patients were judged by clinicians to have have an overall favorable outcome.

Of more recent concern, a 2011 Swedish study appears to demonstrate with varying degrees of statistical support that post operative transsexuals experience more cardiovascular disease, cancer, suicide and all-cause mortality than the general population.  Tipping my hand a little bit, transphobic activists love this study, whether or not they seem to have read it.  Additionally, a British review of more than 100 international studies said that there is no conclusive evidence for the overall efficacy of SRS.  Among the barriers to establishing clinical benefit are studies with poor rates of followup and an alarming number of really shitty papers lacking in scientific merit.  Reviewers concede that in order to really understand the benefits, they would need a large group of control patients who were denied hormones and surgery for comparison, and that doing so would be cruel and unethical given that so far, these interventions are the only things that have been reported as beneficial by the patients themselves.  Finally, just last month Swedish investigators reported that transwomen (MTF) who had hormones and surgery experienced less cardiovascular disease than patients who had hormones only.  This is the most recent of a very small number of studies that recognize transition as a series of possible interventions rather than one process.

Clear as mud, right?  Now that you have the lay of the land, we can move on to the transgender regret controversy, unless of course, you have already learned enough for one day and find you have no further fucks to give, in which case, I bid you a fond sayonara, wish you a Happy Festivus and encourage you to return in 2016 for what will almost certainly be a series of shorter, sweeter posts.

To you very clever souls remaining, I now pose the question:  With so much uncertainty regarding how to optimally treat gender dysphoria, what is so wrong with those who are campaigning to discourage transition?

Heyer projects his personal experience on the rest of the transsexual population.  Heyer spent the better part of a decade receiving treatments which left him feeling maimed, disfigured and deeply unhappy.  I think we can all agree that this is a profoundly shitty treatment outcome.  He came to the conclusion that it is impossible to change gender⁵, and now labors fervently to see that no one else makes the same mistake.

Let’s concede that SRS really was a mistake for Heyer and recognize that he is not the only person to have come to such a conclusion, nor to have de-transitioned.  Still, a bit of proportion is in order.  There are somewhere between 15 and 20 thousand SRS procedures being performed annually in the US alone.  How much prognostic significance can one rationally ascribe to one man’s regret?

For every Walt Heyer, there are one hundred others with no personal experience of gender dysphoria, who display little understanding of the science involved, but who nevertheless commit intense effort and bandwidth to giving others medical advice on the subject .  Even though I disagree profoundly with Heyer, I have no difficulty whatsoever assuming that he has charitable motives.  He suffered greatly, and wants no one else to have to repeat his story.  What drives the rest of the fanatics?  Read their pages if you want to make an educated guess.  Some are peppered with links to ministry sites and others to comment streams seething with hatred for LGBT people, liberals, and “elites”.  Often the two seem to go hand in hand.  Genuine humanitarian concern?  Not much that I can tell.

One of the hallmarks of conspiracy theorists is a reliance on “smoking guns”, i.e. pointing to an anecdote or single piece of data to invalidate a much larger body of evidence.  A parallel example would be the man who witnesses an above average seasonal snowfall in his backyard and concludes that climate change is bunk.  To transphobic activists, Walt Heyer is the smoking gun which confirms their bigotry.  See?  There’s no such thing as transgender.  It’s just a bunch of crazies and queers.

The trans regret crowd tends to draw unsupportable conclusions from the available data, sometimes against the explicit advice of the scientists themselves.  The 2011 Swedish study, for example, really did demonstrate increased mortality risk in post-operative transsexuals, particularly from suicide.  However, as I have previously mentioned, people with untreated gender dysphoria are already at extremely high risk for suicide attempts.  The anti-transition activists conclude that SRS shouldn’t be done because of the risks, but this would be like observing that more people died after heart bypass surgery than those who never had it, then concluding that heart surgery causes death.  Perhaps, instead, having heart surgery is risky, but not having it is worse, and people who need the procedure are already more apt than others to die.  In the authors’ words:

In other words, the results should not be interpreted such as sex reassignment per se increases morbidity and mortality. Things might have been even worse without sex reassignment.

Trans regret agitators imagine a world where sexual reassignment surgery is the common end point of all transgender therapy, and that patients are being corralled towards it.  It isn’t, and they aren’t.  Many trans people don’t seek SRS.  Those who want to medically transition cannot simply choose to do so.  Instead, they must navigate a long, expensive and often humiliating screening process.  First, they must see a qualified mental health professional to be evaluated for the possibility of gender dysphoria.  If verified, they may be referred to an endocrinologist, who may or may not choose to prescribe hormonal therapy.  Prior to evaluation for SRS, the patient must take hormone therapy for at least a year with regular medical followups and engage in a Real Life Test (RLT), essentially living as the target gender 100% of the time.  If they still express interest in surgery they must be seen by at least two physicians who assess for improved psychosocial functioning and fitness throughout the RLT. Wondering if Caitlyn Jenner has had bottom surgery?  Don’t.  At most she is in the latter months of her RLT.⁶   If they certify the candidate for surgery, the patient still must face multiyear waiting lists for procedures costing tens of thousands of dollars.

I have friends who are eager for surgery and others who are less so or not at all. Still others have been forced to give up for reasons, principally financial, beyond their control.  The current screening process can be miserably cumbersome for those committed to that path.  Further, they are generally at the mercy of mental health professionals (whether or not they experience concomitant mental illness) as the ultimate arbiters of their fate in a way that no other person seeking cosmetic or reproductive surgery would have to do.

For better or worse, this is how the system is set up.  The treatment of gender dysphoria starts with slow, gradual and fully reversible steps which must incrementally be followed with frequent re-evaluation before more drastic and irreversible steps are considered.  Trans regret sites often count those who tried and stopped an intervention, e.g. hormonal therapy, as cases of de-transition and regret instead of cases of careful and controlled trials of therapy.  There is nothing speedy about the process.  My personal experience is that my psychiatrist asked me what my current level of interest in SRS was at my first appointment and hasn’t mentioned it since.  I certainly don’t feel like I am being railroaded by some nefarious Psychiatric Plastic Surgical Syndicate.

They massively overstate the frequency and intensity of post operative regret.  Numerous studies have demonstrated patient satisfaction rates around 95%, and further state that dissatisfaction, when it occurs, often pertains to unfulfilled expectations or surgical complications more so than recanted decisions.  Trans regret sites grab much higher numbers by mixing and matching from different studies, adding or multiplying non-equal factors, or sometimes simply pulling a number out of their ass.

Yes…the rate of post-operative dissatisfaction for transsexuals really is quite remarkable, but in precisely the opposite manner that Heyer and others suggest.  Consider what the SRS patient can look forward to.  First, they have to stop taking hormones pre-operatively to minimize clotting complications.  This disrupts the sense of wellbeing that the hormones often provide for them, meaning that they show up for surgery a wreck.  Then there is the surgery itself.  MTFs⁷ can expect a minimum of several months of convalescence.  Most procedures eventually result in a visually and functionally convincing vagina, but in those vulnerable hours when patients first awaken, they see a bruised, unrecognizable mess, quickly followed by severe pain, urinary retention, phantom itches that they can no longer scratch and a use-it-or-lose-it cavity which initially requires up to two hours per day of painful self-dilation for 6 months to a year.  If they ever let up in this task, the vagina will close up like an unused piercing.  Eventually becomes stable enough to be kept open by frequent penetrative intercourse⁸, but life being what it is, the dilators will do most of the heavy lifting for the rest of their lives, or as long as they keep up the maintenance regimen, whichever comes first.

For FTMs, hormonal therapy works better⁹, but the surgical prospects are worse.  First, they must undergo the complex psychological screening above before getting “top surgery” (mastectomy) despite the fact that a woman may opt for a nearly identical process (generally for breast cancer risk reduction, although it is not yet medically clear that this intervention actually achieves that goal) simply by signing her consent.  If they should opt for “bottom surgery” (SRS) the complexities ratchet up dramatically  The adage states, “It is easier to dig a hole than build a pole.”  Current technology cannot offer the prospect of a either a visually compelling or a fully functional penis.  The FTM might achieve, depend on which procedure he selects, a cosmetically decent phallus which may or may not be able to pass urine, but cannot become erect.  A different procedure offers a micropenis that can still orgasm, but cannot pee.

These are but tiny glimpses of the harrowing ordeal which transsexual patients endure and yet for the most part find to be worthwhile.  Despite the known hazards and limitations of SRS, people line up for it and experience far more satisfaction after these surgeries than for almost any other for which we have such data.  Better than gastric banding and other bariatric (weight loss) surgeries.  Way better than for non-transgender related cosmetic surgeries.  Hell…better than knee replacement.

They recommend repentance and prayer to transgender people as an alternative to medical care.  If Jesus gets you through your cold, caffeine addiction or cancer, I say good for both of you.  However, I am also in the business of mediating human suffering.  I’ve seen plenty of people cured by God until they weren’t, at which point their further suffering was just confirmation that his ways are higher than ours.  Walt Heyer can ascribe whatever spiritual meaning he wants to his struggle, as long as he follows it up with a hearty YMMV¹⁰  If he found clarity in religion, I am happy for him.  My own experience was that religion so muddied my thinking with guilt and false narratives that I was unable to figure out that I was transgender until well into my 30’s and what to do about it until long after that.  I just lacked faith, or hadn’t prayed enough, or was too busy rebelling against God.  Again, YMMV.

Recommending prayer is probably fairly innocuous, in my opinion.  Recommending repentance however is reprehensible, implying that being transgender is a moral failing, or represents a lack of faith.  Take this burden upon yourself if you must, but doing so to a frightened child who can’t make sense of her identity is abuse.  And the irony!  God would never want you to mutilate your body by “cutting off your penis.”¹¹  He would, however, like us all to hold down screaming infants who could not possibly understand or offer consent and cut off the last little bit on the end.  He put it there to give us an opportunity to show faith.  Besides, it doesn’t really hurt them at that age, right?¹²

This all sounds vaguely familiar.  The sort of fear-mongering we encounter regarding SRS is not without precedent.  Remember Post Abortion Stress Syndrome (PASS)?  Medical experts disagree on whether it exists in its own right or as a special case of PTSD.  My reading suggests that most lean toward the latter, and that if it does occur, it can be difficult to tease out whether the woman suffers stress due to the abortion itself, or from pre-existing factors which may well have entered into her decision to have the procedure in the first place.    However, several things strike me as obvious.   First, there an awful lot of medically and/or scientifically unqualified people–in some cases the very same people–offering expert opinion to complete strangers on this matter.  Second, the critiques I offered above can all be applied to with very little modification to PASS.  Third, opponents invoke a largely hypothetical syndrome in hopes of discouraging, restricting or outright banning others from having this procedure.  And finally, most women, coincidentally enough 95% again, never experience it.

It is no accident that I started to understand what it meant to be transgender shortly after the internet became an efficient vehicle for the dissemination of information.  What was previously embarrassing or even impossible to find out in the public library was now available with a click of a mouse (after that really obnoxious telephone modem sound).  My private hell was suddenly something that also happened to other people, some of whom had stories to which I could relate.   This not to say that I didn’t encounter a lot of junk on the internet too.  You can easily imagine what comes up with the pertinent search terms.

For my part, I am glad that Walt Heyer’s site was not the first that I encountered back then. In my confused state I might have accepted his disinformation and personal opinions as fact.  The best antidotes for propaganda are calling it out for what it is and seeking a greater understanding of what it means to be transgender.  On the medical side, this means more and better scientific study, looking critically at what helps and what does not.  Thanks to research done so far, we are beginning to understand the importance of mental health support for transgender people whether or not they surgically transition, and that surgery itself, while helpful, probably does not completely cure depression or mitigate suicide risk.  This is vital information, but not yet presenting sufficient reason to suggest that the safest course is abandonment of medical and surgical therapies that transgender patients themselves consistently report as helpful and positive.  For your part, it means trudging through what recently seems like a endless barrage of information on transgender issues so that the next kid who looks to you for help might find compassion, acceptance and referral to effective care.

In that light, I genuinely thank you for reading this far.

Competitive women’s tennis died forty years ago.  At least, it was supposed to have.  Mere months after (then) Bruce Jenner set world records in the 1976 Olympic decathlon, a 42-year old ophthalmologist and semi-pro tennis player named Renée Richards applied to play in the US Open Women’s tournament.  The wrinkle was that she was transsexual and refused to be subjected to chromosome testing.  No helpful precedent existed.  Athletes, officials and the sports media all expressed fears of unfair advantage.  Her application was denied, and she sued the US Tennis Association, ultimately winning her case in the New York Superior Court.  In 1977, she reapplied and was accepted to play in the Open, where she lost  to Virginia Wade in the first round.  She lingered in pro tennis for a few years, but left a substantially larger mark on the culture than she ever did in the record books.

The conversation that Dr. Richards started has, if anything, intensified over the last ten years.  The carnival came to my neck of the woods last year when the Minnesota State High School League debated what rules ought to apply to transgender athletes.  The above picture was part of an advertising blitz by “family” groups to block transgender participation in high school athletics.  The MSHSL ultimately decided to adopt rules similar to those laid out by the International Association of Athletics Federations, which I will summarize below.  First, however, I would like to lay out the arguments for and against allowing transgender athletes to compete.

I assume that the answer to the question, “Why would a transgender person want to engage in sport?” is pretty much the same as the answer to, “Why does he listen to punk music?”, or “Why would she want to drive a car?”  There is likely a mixture of whim and utility intermingled in the answer, but the most striking thing about the question is its silliness.  Trans people read, drive and compete for reasons similar to the general population.  Regarding athletics specifically, some seek the health benefits.  Others thrive on competition or are driven by the vicariously fantasies of parents.  A gifted few might have the further enticement of financial renumeration, whether through scholarships or professional status.  Nevertheless, most of us do whatever we do because we simply like to do so.

The most compelling argument against allowing transgender athletes is one of fairness, which I think most will readily affirm as a positive value.  Specifically, the MTF athlete ¹ might possess strength, agility and/or endurance above and beyond that of her peers which result in competitive advantage.  To the extent that is the case, perhaps it makes more sense to segregate by birth sex, which, after all, is easier to establish than psychosocial identity.

The devil is in the details.  One could graph out a range for normal strength, stamina, etc. for males and females and demonstrate that they are different, but they overlap.  The proponents of this argument are not really looking for a measurable talent cutoff.  Their preferred segregation is between the sexes, not between strength and size categories.  Secondly, I have no doubt that Usain Bolt and Carli Lloyd work hard at their sports, but to what extent can we say that they do not enjoy some degree of innate physical advantage?  If we truly want a level playing field, we will have to select more random activities–competitive coin flipping, perhaps.

Muddying the waters even further, what really persists after transition?  It turns out that it largely depends on when the person started hormones.  Male and female body structure is quite similar until puberty.  At that point, the bodies start to become sculpted by estrogen or testosterone.  Estrogen closes the growth plates in bone earlier than testosterone, resulting in lower female stature, and muscle type/mass is significantly increased by testosterone.  One of these differences, you will have guessed, is permanent.  Those MTF’s who start hormones post puberty will likely have increased height and bone density, whereas those who started earlier will be more comparable to natal females.  However, it appears that estrogen therapy brings muscle mass fairly quickly into the female range.  Again, no one is actually arguing for segregation by precise physical measurements when it comes right down to it.  Most transwomen will be somewhat taller, but not necessarily stronger than their co-competitors.  Interestingly, athletes post-transition tend to be as, but not more competitive, than they were pre-transition.²  The world being what it is, maybe there is someone out there just crazy enough to undergo gender transition for the sake of athletic advantage, but there is no evidence whatsoever that it would work.

As I mentioned, the IAAF has established rules that determine eligibility of the trans athlete.  The athlete must report her transition.  She must have legally AND medically transitioned, with the latter being defined as a minimum of one year on testosterone blockade/estrogen therapy.  Hormone levels are to be checked, and the final decision is made by a panel of medical experts.  The process is rigorous, well-defined, and frankly puts a very high burden on the post-transition athlete in terms of extra verifications and concession of privacy.  Parenthetically, transwomen will almost always end up with much lower levels of testosterone–typically zero for transwomen vs. 20-60 ng/mL for natal females.

Once you get past the fairness discussion, the arguments against letting transgender women degenerate rather quickly.  Most of them you can read in the advertisement above.  Transwomen are really men.  Predators.  Imposters looking for easier competition.  Thieves, taking scholarships from “real women”.  Each one of these is a version of You Don’t Count.  This affront, and not hope of personal gain, is what drove the otherwise shy Renée Richards to let herself be cast as “an extraordinary spectacle”³ in the summer of 1976.  She wanted to play, and she didn’t like being told that she could not.

Women’s tennis did not die in 1977.  Richards went on to coach Martina Navratilova to a pair of championships at Wimbledon, where she herself was never allow to play.  She returned to her ophthalmology practice, and apparently still pops back into the office a couple of days per week.  In 2014, two days after her 80th birthday, another quirky fairly late-transitioning forty-something transgender physician stood up in Scott County District Court and testified that she too, would like to be called Renae, reborn.  It was so ordered.

I don’t do drag.

By this I mean to say two things.  First, drag has a specific definition which does not apply to how I present.  Second, drag makes me personally uncomfortable, and I would rather not be one of its consumers.

First things first:  drag typically refers to cross-gender dress for purposes of entertainment or performance.  Drag queens usually do not identify as female, nor do drag kings identify as male.  Many, if not most may not even see themselves as transgender.¹ Drag demands, or at least thrives upon, a stage.  It tends to the garish/outlandish and stereotypical.  While drag performers often seem quite comfortable–more so in fact than many of the other transpeople with whom they are confused–they are not primarily motivated by a quest for comfort.

Dee Snider (above) is a drag queen.  Alice Cooper was.  Eddie Izzard dresses during his performances, but probably is not.  The distinction turns on purpose, and/or whether or not one’s cross gender presentation has anything to do with one’s day to day sense of self.  Caitlyn Jenner arguably presents a caricatured view of femininity, but presumably out of a sense of deep personal conviction.  She is no drag queen.

Drag elicits a reaction.  Indeed, this is the point of drag.  For those who fancy it, it is delectably transgressive, mocking the gender binary by reducing it to absurdity.  Drag isn’t so much about who the performer is as what he or she is trying to say.

Or, perhaps not.  I ought not to overgeneralize.  Many engage in drag because they simply find it fun.  Thousands of people dress in drag on Halloween.  By November 1, they have moved on to something else.  The individuals in question quite probably break the rules merely for the pleasure of do so.  Others revel in the theatrics and artistry, which, I concede, are undeniable.

Still, I don’t like it.  Done poorly, it makes me feel like my life is a joke; done well, like make believe.  The over-the-top spectacle of it becomes, for those unfamiliar with trans people, particularly transsexuals like me, the gestalt of what it means to be transgender.  Drag teems with epithets like “she-male” much in the same way as gangster rap is littered (and, to my eye, polluted) with the N-word.

LGBT events are heavily salted with drag.  One cannot go to Pride Festival, for example, without being utterly inundated by it.  And, as I said, it makes me squirm.  Perhaps this reaction is evidence of the iconoclastic success of drag–after all, some women feel that my feminine presentation caricatures them too.  Might they not also assert that my presence brings them down?

The best that I can do by way of rejoinder is to say that this has never honestly, consciously been my intent.

I don’t do drag.  I do me.

These days, one cannot buy a banana without being asked to fill out a customer satisfaction survey, but six years ago, they were still a fairly novel and challenging development in the practice of medicine.  Though anonymous evaluation can be intimidating, I initially embraced it.  For starters, I thoroughly believed that clinical savvy falls flat in the absence of kindness, respect and good communication.   Further, I had very little negative experience with the surveys.  Generally speaking, I hit it out of the park pretty consistently.

I had not suffered any direct consequences at work for being transgender yet.  Quite the opposite, really.  The nurses suddenly seemed to like me more and Mary, my boss, had played a significant role in me coming out to the hospital staff by communicating some talking points which we prepared along with her personal support.  Then again, the hospital had not yet suffered any consequences on my account either.  A couple of months earlier, when people started to notice and/or complain about my transitioning appearance in my church, the leadership there wasted little time in kicking me to the curb.  Initial reactions aside, would the same happen to me on the job if patients complained?  For the first time, I began to fear public feedback.

The dreaded complaint arrived bundled in a summary of recently returned surveys.  As we took pride in our customer service in the ER, these results were generally posted on our bulletin board.  Scanning through the initial charts and graphs, my eyes gravitated to one of the free text comments listed below.  “Unprofessional,” it said.  “Inappropriate.”  The anonymous author named me, described my appearance, and stated in no unclear terms that he or she found it wholly unacceptable for a person in my position.  Instantly, my heart was in my throat.

Of course there was no chance that this would go unnoticed.  Devastated, I photocopied the comment and walked down toward the administrative offices, where I found Laura, the Director of Nursing at her desk with the door open.

I asked her if she had seen the most recent surveys.  She said she had not, so I passed the photocopy of the comments to her.  She read it in silence, looking up when she was finished.

“As far as I know, this is the first,” I began.  “I doubt it will be the last.”

“No, probably not.” she replied.

“Well, what should we do?” I asked.

She thought again for a moment, appearing as calm as I was agitated.  Then, she picked up the paper, leaned over and tossed it in the wastebasket, adding, “It looks like they answered a question that we didn’t ask.”

Fast forward.  The lunchtime conversation with Mark is at least a half dozen years behind me, but not forgotten.  I am still quite religious at this point, and find myself at church in an adult education class–basically Sunday School, but for big people and, importantly, with coffee and donuts.

A man across the chair circle from me abruptly launches into an unsolicited rant about “the homosexual agenda.”  Witness our subsequent conversation, more or less:

Me:  Do you know that song, “Come Just As You Are”?
Concerned Citizen:  Yeah.
Me:  Could a gay person do that here?
Concerned Citizen:  Well, they have to give up their lifestyle first.
Me:  Why do gay people have to change first if the rest of us get to come as we are?  Can’t God fix whatever needs fixing?
Concerned Citizen:  I suppose.
Me:  And what if being gay doesn’t need fixing?  Have you considered the possibility that there is nothing wrong with them?

He hadn’t.

I don’t remember exactly how long it took me to progress from the idea that there wasn’t anything wrong with gay people to the thought that perhaps there wasn’t anything wrong with me either.  Even now, I don’t always feel too sure about it.  Still, I connected the dots, and decided to quit fighting my transgender identity.

I regret to say that I did not come out the next day in a technicolor blur of fabulousness.  As always, I waded slowly into the water.  I managed to convince myself that I was in a safe place, and that my friends either did not notice or did not care that I was gradually feminizing.  It would be another several years before I found out how wrong I was.

That too, was a milestone, but one I think I’ll leave undisturbed.