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An Overview of the Transgender Experience
Approximately 3-5% of the population are reported to have had significant feelings of discomfort about their gender identity (gender dysphoria). Yup, that is one heck of a lot of people, the Guess clothing company knows, check their multi-million dollar ads and you’ll find gender blending on every glossy page.
So who is this highly visible yet unrecognized population? Here is a quick guide to some of the types of folks who live within the spectrum of transgendered experience.
When a person has an internal gender identity that is congruent with their physical sex they are referred to as cisgendered. To identify as transgendered (tg) in the broadest sense is to have significant feelings and expressions of the gender characteristics and roles normally assigned by society to persons with the genitals which don’t match your own.
Transvestites (tv), and crossdressers (cd), fit in here, they like to wear the clothing of and sometimes present in public as if they were members of the opposite sex. For the majority of crossdressing males this is often a stay at home activity. Females can publicly wear the clothing of males without great risk of physical or social harm. An average male does not, at least in Montana, show up at work in anything too pink, lacy or “soft.” Oh, and most all men who crossdress, off the runway anyway, are by preference heterosexual. Drag Queens by preference are gay enjoying the fun of the other side of the clothing store and stage performances.
A transsexual (ts) identifies completely as the gender opposite of their birth assignment and desire to live on the other side permanently. This is true for born females who wish to be male (female to male or ftm), and males who want reassignment to become female (male to female or mtf). A transsexual wants not to just “pass” as the other gender, but to be and live full time as the other gender. This process of moving from one gender to another is called transition and the ultimate goal for most is sexual reassignment surgery (srs).
Complete transition going either direction, ftm and mtf, involves a process that may take 3-4 years or longer. Transition often begins with counseling by a therapist familiar with gender identity issues. Next task is to select a primary care physician who is knowledgeable about a process known as Hormone Replacement Therapy and is willing to assist the person in that process. During the transition process other resources such as hair removal, physical training, changes in clothing, hair styling, speech training all help when needed to help us learn how to "be" in the world in a gender we were not socialized. Then there are steps like preparing an employer, a school, ones family and friends about the change in name and preferred pronouns. Name and pronoun changes are important also for folks who identify as non-binary, gender fluid, gender queer, or non-gendered.
Trained counselors, physicians, and surgeons who work in this field are guided by the World Professional Association for Transgender Health (WPATH) The Standards of Care are internationally accepted and used by all reputable clinics and practitioners.
After beginning hormones, at least one year must be spent in a Real Life Test (rlt) where the person lives full time in their new gender. This offers the Transperson the opportunity to see if they can live successfully in their new gender identity. The rlt is a major step involving legal name changes, adjustments in work, family, and social life, as well as a myriad of internal learnings.
After completing the rlt, and on approval of the treating therapists, the T can then pursue Gender Reassignment Surgery (grs). These surgeries permanently alter the bodies primary (genital) and secondary (breast, face, torso) sexual characteristics. There are many clinics in the U.S. and abroad that specialize in these surgeries. For resources for ftm surgeries, please consult FTM Information Network or Hudson’s Guide.
The process for learning about life does not stop after surgery as each transperson finds their unique place in life. Some choose to blend in and find a life where their “other life” is hidden. Others choose to stay involved in the transsexual community working for social justice and for mutual support.
What the Research Says
An increasing body of research indicates that there are neurological differences in a transsexual personas brain which may explain why they just don’t feel like their genitally assigned body matches who they are.
Transsexuals live with the highest level of gender dysphoria, which takes its toll in depression, guilt, shame, and anxiety. More than 50% of T’s attempt suicide, sometimes by placing themselves in harm’s way by choosing to participate in high risk activities.
It has been estimated that approximately 30% to 50% of persons who identify as Transsexual do not live past the age of 30, mostly because of suicide. In story after story in conversations with transsexuals you hear of the choice many make between coming out and beginning transition or suicide. The desire for gender change is strong, it is permanent and no amount of therapy of any known type has yet proven effective in eliminating the transsexual identity. Attempts to change a transsexual to be “normal” can be and have been lethal for some. For the true transsexual the only known helpful process is outlined by the Benjamin Standards: hormone therapy, corrective surgery, and life coaching through the transition into a gender that is congruent both inside and outside.
One of the most difficult struggles for a T or any other transgendered person is dealing with their family and social group. Many people do not come out of their closets, literally sometimes, until middle age or until after they are married and with children. It is very important that a t person seek assistance with their situation for themselves and their family.
There are now both local and international resources for all transgendered persons, their spouses, children and parents. The Gender Expansion Project serves the trans*, intersex and gender variant communities throughout Montana and beyond with its trans-inclusive programming, resources, and trainings as well as its chapters of the Montana Gender Alliance
All About the Surgeries
During SRS the body is surgically altered to simulate the genitals of the gender of choice. The process is a significantly more satisfactory in both appearance and function for MTF patients than for FTM patients.
The following includes excerpts from a book by Melanie Anne Phillips, Everything You Always Wanted to Know About Transsexuals: “Contrary to popular belief, the penis is not amputated during SRS. Rather, the internal penile tissue is mostly removed, but the outer skin is left attached, inverted and inserted into the body inside out as the new vagina. Here is how it happens. Once the patient has been prepped, sedated, wheeled into the operating room and anesthetized, the doctor slits the skin of the penis lengthwise from the head or glans down to the base on the underside. The skin is then peeled away from around the penis, but since the slit only opened the penis, the base of the skin is still attached.
The penile skin is then turned inside out, much like one might turn a sock inside out. When this is done, the slit is stitched back together, creating an inverted penis, which will ultimately form the new vagina. Before this occurs, a rather miraculous, yet simple procedure is performed. Earlier, when the internal penile tissue was removed, a small stub of tissue was left behind, still attached. This is erectile tissue, which becomes stiff when stimulated, and also carries sexual sensation.
A tiny slit, perhaps a half-inch in length, is made in the new, inverted penis near the base where it is still attached. The stub of erectile tissue is pushed through the slit, forming the equivalent of a clitoris, and providing the opportunity for complete orgasm and sexual satisfaction after surgery. In addition, a second tiny slit is made below the one for the clitoris. The urinary tube is rerouted to this second slit to create a typical female urinary opening.
Once this procedure has been accomplished, the skin and muscles of the lower abdomen are lifted up with surgical instruments, providing a gap near the pelvic bone. The inverted penis is pushed into the gap, still attached at the base, so that it hinges down and into the proper location for a vagina.
To allow for proper vaginal contractions later, some of the abdominal muscles are repositioned around the new vagina so that they can squeeze in on it, both by conscious control and also automatically during orgasm. The primary vaginoplasty surgery takes between 3-5 hours. The new vagina is filled with surgical gauze to maintain shape, and then anchored in place with a thin surgical wire which enters the abdomen from the outside, runs under the pelvic bone, through the new vagina, back up around the pelvic bone and out the abdomen again. Once the vagina has healed in place, which takes approximately seven days, the wire is removed by the surgeon, who simply slips it out.” After this initial procedure to form the vagina, create a clitoris, and rearrange the urinary tract, there are weeks of recovery and a dilation routine to enlarge the neo-vagina to its final dimensions. A second procedure is often then performed to create the additional labia tissue.
The surgical procedures for FTM’s often starts with a chest reconstruction surgery, the removal of almost all breast tissue, reduction and relocation of the aureole and nipple to more reasonably resemble a male chest. The results of these procedures can be amazingly acceptable and they are the most common surgical correction sought by most FTMs.
The surgeries to create an aesthetically appealing and functional penis are still a long way from perfected. There are procedures to use extensive skin grafting from arm and leg skin to create a penis, which can hold the urethra, but alas there have been no successes at creating erectile tissue. For many the appearance of these neo-penises is often not worth the longer surgery time, 10-12 hours, and the costs which are often 2 times greater than those for MTF patients. Many FTM persons experience an enlargement of their clitoral tissue once they are on the male hormone regime. With another surgical technique, called a clitoral release, the clitoris can expand even further forming an aesthetically appealing although small penis looking organ.To view current information on many aspects of MTF transsexual surgery, hormone therapy, and view results from various surgeons, click here go to Dr. Anne Lawerence’s Web site. To get current information about FTM surgeries, hormone therapy, and view surgical results, click here to go to the Female to Male Resource Network Page
Safer Sex
Safer Sex Post-SRS
This article is written to address questions about sexual safety after sex reassignment/realignment surgery (SRS). This is not because we assume everyone has or wants SRS, or that surgery is required in order to be fully female or male. When doing research, we discovered that there’s not much information available on post-surgical sexual health, so we figured we should try to put some out there. We encourage readers with first-hand experience (whether that’s your own hand or someone else’s) to let us know what’s been working for you with regard to safe post-op sex, or what you know works well for clients—this article is only a start, and we look to the experts (you!) to share more information.
A word also about language used in this article: We deliberately avoided pronouns and “FTM/MTF” designations as much as possible, so as to better focus on body parts and sexual activities. This is because tissues heal more or less the same way in everyone, and viruses and bacteria don’t care about gender identity, sexual orientation, or how a person calls themselves before or after SRS. They only care about setting up shop in the human body, and whether what we’re doing with our bodies helps or hinders them in that goal. With that in mind, let’s take a cruise down SRS Lane.
In order to discuss post-op sexual activities and risk factors, we need an understanding of what sexual reassignment/realignment surgery (SRS) entails. SRS comes in many packages—some people opt for the full range of “top” and “bottom” procedures, while others pick and choose according to their priorities and needs. Below is a chart providing very basic information on SRS procedures, including healing times and post-op concerns.
Since healing from SRS can be a slow process, you need to keep your new parts safe while they’re getting used to the world. Risk of infection is a major concern for all who undergo SRS, but even more so for those living with HIV. SRS involves major surgeries performed on delicate parts of the body, and healing requires your body to re-wire nerve responses and recover from blood loss in addition to repairing tissues. Take care of yourself after surgery! Do not push yourself past your limits, work-wise or sex-wise! You’re going to have your genitals for the rest of your life, so no need to jump on the horse before your body says it’s ready to ride (if you know what I mean).
Ask your medical team when it’s safe to experiment with sexual penetration, and listen to your body when you start out. If you are living with HIV and/or Hep B and C, it’s especially important that you wait until your post-op bleeding and wound drainage is over before resuming sexual activity, both for your own health and that of your partner. This includes anal sex as well as genital sex, since the muscles and tissues of the entire anal-genital area are involved in SRS and must be allowed to heal too. Follow your medical team’s post-op instructions carefully for optimal healing, take it slow, and use lube when you start having sex again. Traditional or Reality condoms are good protection against blood and wound fluids that might not be easily visible. For those who use sex toys, clean your toys properly before and after penetrative sex, and
Contrary to myth, neo-vaginas are not more resistant to infections than natal vaginas. Whether your neo-vagina is constructed out of your former penile and scrotal skin or from a section of your colon, your genitals are delicate and limited in their stretch capacity—your dilation exercises will give you a good sense of what’s comfortable and what is too much. While women have been known to experience some natural lubrication from urethral tissue or Cowper’s and prostate gland secretions, most neo-vaginas are not self-lubricating. Therefore, lube is an even better friend than it was before SRS! The more lube used, the more comfort and the less risk of tearing.
All vaginas can end up playing host to vaginal and bacterial infections, sexually transmitted or naturally occurring. Vaginas are among yeast and bacteria’s favorite places to live—the dark, warm, enclosed environment is perfect for their breeding needs. Close proximity to the anal area also increases the odds of bacterial vaginal infections, so get used to wiping front to back now if you aren’t already. Your partner/s should also use condoms on their penises or on sex toys to help further reduce your risk of neo-vaginal infection.
Herpes simplex virus (HSV I or HSV II) can be transmitted to your new genitals via oral or genital sex, or an old HSV infection may flare up as your immune system prioritizes healing from surgery. Keep an eye out for discharges, odors, tissue irritation, small sores, and/or itching or pain—skin irritations and sores can bleed, as well as leave open pathways for HIV and bacterial infections. Douches will be prescribed to help speed your surgical-site healing, but douching can’t be counted on to clear up a yeast or bacterial infection, and it won’t help with herpes. If your vagina was constructed out of penile skin, you may also experience itching and discharge related to hair growth in your neo-vagina. Given all the possibilities, it’s worth a visit to your doc or clinic if you notice anything unusual.
Condoms are an important part of sexual safety for all men, including those who don’t produce semen (ejaculate, jizz, spoo, cum, etc.). Neo-phallus skin needs protection from HSV and HPV, as well as yeast infections of the skin and bacterial urinary tract infections. If you have a penile prosthesis implanted as part of your SRS, condoms will also help reduce the risk of infected micro-tears as you learn how your new penis skin stretches during erection and penetrative sex (put the condom on after inflation, just like you would with any other erection). Men with ”trannycocks” resulting from metaidoioplasty may find traditional condoms too large for fun or safety. A suggestion from James Cullen’s “Safer Sex for Transguys” pamphlet is to “…cut a (latex or polyurethane) glove along the thumb side from the wrist down to about where your first thumb knuckle would be. The thumb of the glove becomes your condom, and the rest of the glove hangs free to cover all the other important stuff from your cock to your ass.”5 Another option is to cover your own or your partner’s genital or anal area with a dental dam, and then enjoy yourselves.
Anal sex can be enjoyed safely post-SRS healing with a few precautions. Lubricants and condoms are the easiest way to keep skin happy and body fluids contained—water-based lubricants must be used with latex condoms, but oil- and silicone-based lubes are safe for use with polyurethane traditional or Reality condoms. Bottoms of any gender can use Reality condoms to protect their butts and their partner’s penis. Tops can protect their natal- and neo-phalluses—as well as their partner’s vagina or ass—with traditional condoms. Also use fresh condoms if alternating between anal and vaginal penetration, to reduce the risk of vaginal infections caused by butt bacteria and STIs in any area.
Sharing hormone syringes and other injection equipment carries the same risks as sharing equipment for recreational drug use, even though hormones are injected into muscle instead of a vein. Hepatitis C is of particular concern, since this virus is much more durable and easily transmitted than HIV. Please don’t share equipment! Many syringe exchange programs can provide hormone-grade syringes if you run out or don’t have a prescription. Please also consider the risks of using street hormones, even if you have an ongoing relationship with your supplier and bring your own injection equipment or see the equipment packages being opened. As with recreational drugs, you never know for sure what you’re going to get on the street. Injected silicone can cause severe health problems, along with injection-related scarring and infections. Regardless of where you get your therapies, please keep up with regular clinical monitoring so any health complications can be addressed quickly.
Another note: Some of what you’re born with, you keep. If you were born with a male body, you have a prostate gland up there in your rectum. Your prostate remains even if you have SRS, so remember to get that checked once a year and anytime you notice rectal pain, frequent urination, or any other sign of prostate trouble. If you were born with a female body and have not had a full hysterectomy, you have a cervix that needs to be screened for cervical cancer. If you are HIV-positive, follow the guidelines for prostate exams and Pap smears that are suggested for your natal gender: once a year for prostates over age 40, and once a year for cervixes (more often if you have a history of abnormal Paps). If you have no cervix, natal or neo, an annual pelvic exam is recommended, though the value of vaginal Pap screening is unclear at this time.6
Speaking of Pap smears, anyone who has receptive anal sex is now encouraged to get an anal Pap to screen for HPV-related anal cell changes and cancers. HIV-positive people are at especially high risk for developing anal cancer, due to the immune system’s compromised ability to keep HPV under control. Butts are butts are butts no matter what your gender, so don’t shy away from the anal probe! Once-a-year screening is recommended for everyone with a history of receptive anal sex, regardless of HIV status.
Just as everyone has a butt, everyone has breast tissue. This means everyone needs to think about breast cancer. Even if you’ve had chest/top surgery to remove breasts, you need to do monthly breast self-exams and get a checkup if you notice unusual lumps or growths, especially if the lump sticks to your chest wall and can’t be wiggled around. If your breasts are created via hormone therapy or “boob job” augmentation surgery, you too need to do a monthly breast self-exam. Neither testosterone nor estrogen therapy appears to increase the risk of breast cancer, but breast cancer is becoming increasingly common in general—can’t hurt to check yourself out, even if you consider your risk to be low.
For some transgender people, the idea of sex may trigger feelings of gender dysphoria. For others, they are fine with their genitalia, regardless of their gender identity. It depends on the individual and when they are ready to have sex. Safe sex practices for pre/non-op transgender people correspond to the same concerns that cisgender people have when it comes to safe sex. For penis to vaginal/anal penetration, be sure to use condoms and lubricant, and to change condoms when switching between the anus and the vagina. When practicing oral sex on a vagina, be sure to use a dental dam. If you use toys (non/pre/post-op transmen in particular often use strap-on dildos for penetrating their partners), be sure to clean and disinfect them properly, and to cover them with a condom during penetration.
Online Resources
Transgender Living
Transgender Living, aka grishno.com is a site run and supported by Erin Armstrong of TransThrive in San Francisco, CA. The site provides resources, forums, and a wealth of v-logs for individuals of trans-feminine identity.
www.transgenderliving.com
Hudsons Guide
This Guide is intended to provide information on topics of interest to female-to-male (FTM, F2M) trans men, and their friends and loved ones. Non-trans men have also found the pages on men’s grooming and clothing to be helpful. Transsexual, non-transsexual, intersex, transgender, genderqueer, questioning, and “just plain folks” are all welcome.
www.ftmguide.org
PinkEssence
A Social Network of Trans Identifying & Gender Expressive Individuals, Partners & Supportive Allies. The site features a moderated chatroom, forums, trans-inclusive resources and other social networking features.
www.pinkessence.com
TLDEF
Transgender Legal Defense & Education Fund is committed to ending discrimination based upon gender identity and expression and to achieving equality for transgender people through public education, test-case litigation, direct legal services, community organizing and public policy efforts.
www.transgenderlegal.org