GID: exclusion for top surgery coverage

When I started moving forward with the process of getting top surgery, I did so with the assumption that I would be paying in full out of pocket.  My therapist had looked into coverage a while back, for me, and told me it was not covered.  Still, though, times are changing, and I had a sliver of hope that my insurance plan might have been updated.  In my state, government funded health care now fully covers transgender related treatment and surgeries.  Maybe mine would, by now, too?

Yesterday, I was on the phone with a customer service person for over an hour.  At first it seemed promising.  I gave her the category number – F64.1 (gender identity disorder in adolescents and adults) and the code for the surgery type – 19304.  She said, “Double mastectomy?” and I said, “Yes.”  She then proceeded to try to find out whether the surgeon was in network or out of network.  She told me that if she’s in network, I would be paying a total of $70.  If she was out of network, I would be paying a $750 deductible, and 80% would be covered beyond that.  I started to get my hopes up – either of those would be awesome! – but also remain skeptical.  The customer service rep made calls to my surgeons office, to the surgical center, and to some other places.  She determined in the end that it would be out of network.

At that point, I said, “OK, I just want to make sure you’re doing this through the category of gender identity disorder?  It is a gender-related surgery.”  She responded, with a blankness in her voice, “That’s an exclusion under your policy.”  I replied, as my heart sank a little, “OK so nothing will be covered.  So it doesn’t matter whether she’s in network or out of network?”  “Correct.”

I was mad that she overlooked the category I gave her, as a first piece of information, and moved forward as if there would be coverage, only to let me down.  And that once I made it clear, she didn’t have anything more to say to me that might be helpful.

I asked her about the appeals process.  She said I would pay for and get the surgery, the office would submit the claim, the claim would be denied, and then I could work toward getting some reimbursement.

I brought her attention to a 7 page document that is called Medical Policy, Subject:  Gender Reassignment Surgery.  It lists criteria that need to be met in order for a surgery to be deemed “medically appropriate.”  I asked her what this was, and what would happen if I gathered enough information to move ahead with this.  I told her it was difficult to understand exactly what I was reading.  She said she was reading along with me, and that yes, these policies are confusing.  She then put me on hold again, and when she came back, she completely derailed that conversation – she steered me back toward the exclusions.  She added that not only was the procedure excluded on the basis of gender identity disorder, it was doubly excluded because it falls under “cosmetic surgery.”  The conversation was basically over at that point.  I stayed on the line to complete a survey about the call, and I gave her good ratings because she was way more helpful (making multiple phone calls on my behalf) than I was expecting.

I keep going back to this medical policy document.  I don’t know for sure, but I have this feeling that it’s the loophole for filing a grievance.  That if I can prove it’s medically necessary, I have a shot at getting at least partial coverage.

However, the criteria are so extremely binary in nature.  Some examples

The patient has completed a minimum of 12 months of successful continuous full time real life experience in their new gender, with no returning to their original gender, including one or more of the following:
1. Maintain part or full time employment; or
2. Function as a student in an academic setting; or
3.Function in a community based volunteer activity
And:

The patient has undergone a minimum of 12 months of continuous hormonal therapy (unless contraindicated)
I would have to have two letters from licensed health professionals, one of them being from a psychiatrist or psychologist (that part would be easy).  If one could be from a psychologist, and the other from a psychiatrist, I just might be able to put something together (with a little stretching of the facts…)  If one has to be from a doctor or other medical health related person, I may be out of luck…
I’ve had close to 3 continuouos years of HRT (although I am not currently on HRT, and I did not move into the opposite gender).  I’ve had 10?  12?  years of continuous real life experience, although it has not been full time.  It has been in my “new gender” even though that has not been the “opposite gender.”  There is nothing in there about having to legally change your gender or name (good).
I’m not sure how to proceed exactly – all I know is that it’s going to be worth a shot…

I was on a panel

I’m much more of a writer than a conversationalist – and definitely not a public speaker.  Tons of people have a fear of public speaking.  I don’t mind being in front of audiences, so at least I have that first hurdle out of the way.  I just have a fear that I won’t be able to talk naturally and coherently.  Despite this, I’ve had aspirations for a long time to verbally share my experiences, be on panels, join the speakers’ bureau, etc.  I’ve talked a few times in front of audiences, mostly as part of drag performances.  I’ve gotten around the talking thing by preparing statements ahead of time, reading out loud what I’ve written.

I’ve never seen someone on a panel read before, but I figured, I could do it!  Why not?  I had seen a message posted to a facebook group, from an acquaintance who works for Planned Parenthood.  She was organizing a half-day of training about trans-healthcare for the PP health center staff:  clinicians, nurses, health center managers and front desk staff.  It was going to include a 45 minute panel, and she was looking for trans-people to talk about their experiences with health services – both positive and negative.

I thought my recent consultations with surgeons for top surgery would illustrate a stark contrast, so I emailed her about it and included links to these two posts:

Top surgery consultation #1

Top surgery consultation #2

She wrote back saying it’d be great to have me, and I could certainly read out loud.  Over the weekend, I edited these so they’d work better spoken out loud, and I tried to cut them down shorter.  Because, dang, they seemed short when I wrote them, but it takes more time than you’d think to read things out loud!

I arrived at the venue Monday morning, and I wasn’t even that nervous!  I recognized one of the other people on the panel, which was cool.  The third person came in shortly after, and we introduced ourselves – her name is Leah.

I went first to get it out of the way; I introduced myself and then just launched into it.  I think, in retrospect, that I was talking too loudly (definitely not quite my natural speaking voice) but, that’s OK – better too loud than too quiet I guess.  The other two people went, and they both did an awesome job speaking off the cuff.  We answered a bunch of questions, and I was grateful that the person on the other side of me naturally answered first, giving me time to formulate something to say.  It all went really well – people had great questions!  (As an interesting aside, there were about 75 people in the audience, and it appeared to be made up of 1 man / 74 women.)

The organizer then presented us with gift bags and gift cards, which was awesome!  I feel like the norm is that panel participants are just volunteering, so that was awesome that we were compensated.  We lingered while the group wrapped up their training, ate some bagels and had some coffee, and then stuck around in case anyone had any further questions.  No one did, but we got lots of compliments and thanks, as people were leaving.

This was totally worthwhile and something I’d like to do more of.  I’m not sure how I will transition from reading things into actually becoming a speaker, but, well, it’s something to work on.

The next day, one of the bloggers that I’ve been following for a while, The Overflowing Closet, wrote this post (as part of the 30 day trans-challenge she’s doing:  Day 8 – “How do you deal with being misgendered in the beginning of transitioning by people?”  She started by saying, “Yesterday I gave a talk in front of 75 medical staff and personnel about my experiences being transgender and seeking medical help.  The crowd was filled with people who wanted to provide better services for trans people, and one of their biggest concerns was misgendering people.”

I suddenly realized that the Leah I had met the day before is the same Leah whose blog I’ve been reading!  Has this ever happened to you?  Where you’re reading a blog and then you meet someone and then you connect the dots in between?  Such a cool experience!  I contacted her to see if I could share this, and she said of course.

So hey, here’s to making something out of all this writing and online connecting with people!


I came out to my co-worker

I have been coming out to my (newer) co-worker in stages, over the last year or so.  At first, I just wanted him to stop calling me “honey” and “girl.”  So I told him that.  He asked about “brother” and “man,” and I said those were fine.  He easily made that switch.  I think he saw me as a butch lesbian.

He initially used to talk to me about his gay step-son, but over time, that changed into him talking about his transgender step-daughter.  She is transitioning while in high-school; I can’t imagine the stress of that!  My co-worker seems supportive if not a little critical about how she chooses to present herself.  So, with that door opened, I’ve talked to him about how I don’t feel either male or female.  He has asked if I would make medical changes, and I have been vague.

About 2 months ago, we were in the faculty lounge, and the newspaper was on the table.  The front page had an article about a new radio station I was getting involved in.  So I pointed it out to him and told him I’m a DJ.  He was super supportive and excited, asking me how he could listen, if he could come down and check it out, what I was playing, and if I had a radio handle.  I suddenly felt cornered because I don’t have a DJ name, I’m just going by Kameron, which is not the name I go by at work (yet.)  But that feeling melted away into, “it will be fine to tell him.”  So I did – told him I use a different name on the radio and outside of work, and I talked to him about how I would like to switch and use this name at work too, but it’s hard.  I also said I go by male pronouns.  He took it all in stride, more excited about the radio thing than anything else.

He has started to call me “Kam” when no one else is around.  I do not promote the use of “Kam” as a nickname, but coming from him, it is endearing.

Then last week, we were talking about his step-daughter again, and I segued the conversation into how I will be getting top-surgery.  (I had mentioned this once before, hypothetically, and he seemed confused, wondering if I was going bigger or smaller – because it probably seems like I have nothing there.)  I figured he is one of the few people I would fill in about why I am going out of work, and the sooner I can get some of that out of the way, the better.  I expressed my anxiety about telling our supervisor and about coming out at work in general.  And about what to say to whom.  It does feel good to be able to be open with one person at work, at least.

Yesterday, for the first time ever, I could clearly see the steps it would take to come out at work.  And it felt like I could actually do this.  Currently, my supervisor is out of work, so I’m not going to be doing anything about it anytime soon.  I feel like talking to her is the biggest hurdle.  If I could do that, the rest definitely seems do-able.  Part of me wants to skip talking to her, and just let her know via email, like everyone else, but I don’t think that would be wise…


Year end / I scheduled top surgery

2015 has been one of the hardest years of my life.  I was majorly depressed for 4 months of it.  I was moderately depressed for the vast majority of the rest of it.  I was out of work for a total of 2 months due to mental health issues.  I was in the hospital, and I was also in a partial hospitalization program.  I did do some fun things (like camping, going to Pittsburgh, marching in the pride parade, adopting 2 cats, going to the beach 3 weekends in a row, becoming a radio DJ, seeing Sleater-Kinney) but they failed to feel like much fun.  I’m only now starting to feel like myself for extended periods of time.  For example, today and yesterday (but not the day before), I felt like a person in a normal mood, and that felt great.  I hope tomorrow feels like that too!  I started on a new medication 2 weeks ago, and I’m really hoping something clicks…

I wrote a similar post last year, and I summed up gender-related stuff this way:
“I continued to settle into a new and improved place with hormone therapy and talk therapy, but I’m finding I still have a LONG way to go until I really am where I see myself.  I want to be out as non-binary in all areas of my life.  I want to go by a different name.  I want all the people who know me to use male pronouns in reference to me, not just most of the people…  I might want top surgery…”

I made some pretty big strides – I started to go by a different name, and now all my friends and about half of my family use that name.  It’s still growing on me – it feels about equally as strange as my former name feels, now, but that is actually progress.  Currently it feels like neither name really is my name, but I think that’ll shift with more time.

This year I went from feeling like I might want top surgery to scheduling a date!  This feels like my biggest accomplishment, based on the amount of mental headspace this topic has been taking up.  I’ll be going to Dr. Rumer on June 1st.  I chose this date because I purposefully want to miss certain things by being out of work.  I really do not like working in the summers, and I especially have a hard time with the transition from school-year to summer.  I have a lot of sick time accrued, and I plan to use a lot.  Often, people can be back at a desk job 2 weeks after surgery, but since my job is so physical, I plan on being out for 8 weeks, as of now.  Why not?!  That’ll allow me to miss the last 3 weeks of school plus half of the summer.  That would be really amazing.

So if I were to sum up gender-related stuff now, a year later, it’d look like this:  I want to be out as non-binary in all areas of my life (still).  I want to come out at work, so that pretty much everyone will be using my new name and male pronouns in reference to me.  No more dual identities.  I want to get through the ordeal of surgery without too much psychic pain (physical pain is fine).  I want to wear t-shirts!  I want to make up my mind about testosterone – take more?  take less?  go off of it?  I want to legally change my name at some point…

These are not resolutions, but it will be neat to go back and see if I made more progress or not.

Other things I’d like to focus on in the coming year:
– Getting back to being more social.  Being social this year was too difficult, so I didn’t push it.  I’ve been a little more talkative with teachers at work lately, and I’d like to re-connect with some people, both locally and through writing letters to far-away friends.
– Enjoying the summer.  I never enjoy the summer – I usually get depressed.  But since I’ll be most likely out of work for half of it, maybe I’ll feel it more.  I’d like to do a road trip, more time at the beach for sure, maybe some backyard fires, weatherproof our picnic table and actually use it, and go on walks.
– Taking more photos.  My dad gave me a new camera for my birthday/xmas, and I want to use it!
– Giving myself a break.  I’ve been pretty hard on myself, and I’m going to try not to be (as much).


I came out to the head of the kitchen at my school (workplace)

About 7 months ago, I came out to the principal at school.  She asked me what she could do, and at the time I said nothing right now, but eventually I’d like to send out an email and go by a new name and male pronouns.  I still cannot foresee when this email might happen, but I did get myself one step closer a couple of weeks ago.

I was filling in for my supervisor (working during the day while school is in session) and so I had some time to drink coffee in the kitchen and stuff.  About a year ago, I told the head of the kitchen that I was getting testosterone from my doctor (because I was leaving to go to an appt. that day), and that I don’t feel like either a man or a woman.  She didn’t say much at the time, but it felt pretty exhilarating to tell her anyway.  She was also the first person at work I told I was getting married.  One week before the date.  I barely see her unless we’re working together over the summer, but over the years and years and years, I feel somewhat close to her, closer than anyone else probably.

So we were sitting drinking coffee, and this was around the time I was going to be taking a day off to travel outside of Philly to go to a consultation for top surgery.  We were talking about the time off my co-worker was taking, so I just said that I’m taking a day off and I told her why.  At first she was surprised and asked me why I would be getting surgery (she might have thought I had breast cancer?).  I explained that I don’t like my chest the way it is, and I talked to her again about how I don’t feel like either a man or a woman.  We talked about what she’d do if she did have breast cancer, and we talked about people who have gotten breast reductions.  I then told her I’d like to go by male pronouns and a new name at work, but I’m just not there yet.  She said, “Well you need to do what will make you comfortable.”  Then a teacher came in needing something, so the conversation was over.  But I was pretty much in disbelief I was able to tell her all this.  It wasn’t premeditated like talking to the principal was.  And she seemed to react positively.

Normally at work, I don’t see her because our shifts overlap by only about a half hour, and I don’t really have a reason to go say hi every day.  But a couple of days after my trip, she came and found me and asked me about how it went.  It made me feel really good – I did not expect a follow-up.  I told her the out of town consultation went really well, and the one with the local surgeon did not go well.  She name dropped a local plastic surgery practice that might do what I’m looking for, and I found out later through a facebook group that some trans-guys have gone to one of the plastic surgeons.  Not sure whether I would pursue that or not, but it was nice she was thinking of me.

I’m not sure what’s holding me back from coming out at work, exactly, but it does feel like these spontaneous conversations are just more natural than a mass coming out email would be.  I still think the email is necessary because I can’t talk to every person (or even more than a couple), but it just feels daunting…


Top surgery consultation #2

Content warning:  discussion of self-injury.

On Monday, I traveled to consult with Dr. Rumer, and the appointment went well.  In stark contrast, I had a terrible consultation with a local surgeon, at a cancer center, yesterday.  She mainly works with breast cancer patients, and the mail / paperwork I received in advance reflected this.  (The center could easily draft up non-cancer related documents for trans-clients!)

I was there for a total of an hour and 45 minutes – lots of waiting!  When I got there, I filled out paperwork about my breast cancer diagnosis.  I just put N/A for a lot of it.  Here’s a sampling of questions I was prompted to answer:

– What do you know about your diagnosis?
– Previous breast history?- Some cancers are more prevalent in persons of different racial and ethnic backgrounds.  The following information will help us to better understand your potential risk in developing certain types of cancers and to understand your prognosis.  [Followed by questions about ethnicity.]
– What percentage of waking hours do you spend up and about?
– more than 50%
– less thank 50% – I am confined to a bed or chair
– I am completely disabled, totally confined to a bed or chair

On the phone, when I scheduled the appointment, the woman was sensitive to the reason I was coming in, and to the fact I hadn’t legally changed my name yet.  Regardless, that didn’t translate over to the present day, and I was called by my birth name and even, “Mrs. [last name].”  I don’t think I’ve ever before been called “Mrs. [last name].”

I finally was brought up to the breast cancer suite and my vitals were taken.  I waited in an exam room and a nurse came in and went over some of the questions with me.  She left for a while and came back, saying, “let’s fill out this paperwork.”  This one WAS relevant to why I was there.  I asked her, “Why was I filling out papers for breast cancer patients?”  She replied, “Oh, well, they just gave you the wrong one down stairs.”  No big deal… ???

She left and a doctor with an intern student came in.  The doctor asked if it was OK if the student was present, and introduced her.  She then asked, “Are you so-and-so?”  I said no I’m not.  She said, “oops, sorry, wrong room.”  I sat there waiting a while longer and finally the surgeon came in with TWO student interns.  At no point did she ask for my consent for them to be present.  They introduced themselves and we got started.  She started by putting words in my mouth – “So you’ve felt this way since you were a teenager.  That’s when you started feeling different…”  I just let her roll with that.  She asked about mental health, suicidal thoughts, and even self-injury.  I’m not sure why.  She asked very little about gender identity.  I answered her questions honestly, including that I’ve had vague suicidal thoughts, and I used to use self-injury as a coping mechanism.

She then said they were going to leave the room and prompted me to put the robe on.  They were gone a very long time.  They all came back, rubbing hand sanitizer into their hands.  I had a flash fear thought – are all these people going to be touching me?!!!  Fortunately only the surgeon touched me, but the presence of all these people was enough for me to check out for this part of the appointment.  A few things that registered:

– She commented on my tattoo, asking if that was magic marker – it looked like marker.  ???
– She talked a lot while I was sitting there half exposed.  She described the procedure she would do, and manipulated my breast in her hand to demonstrate it.  I looked down briefly, and seeing her grabbing my breast was totally surreal.  She was talking at my chest, and not to my face.  I was poked and prodded a lot more than seemed necessary.
– She actually said to me, “This scar, is this from cutting?”  I could not believe I was being asked this.  I was in shock.
– I was aware of interns in the background, watching this whole thing.  They were fuzzy.
– I said to her, “I’m just in the consultation phase, and I have some questions for you.”  This changed the dynamic and she wrapped up the part where I was sitting there, vulnerable.

When this part was finally over, they left and I got dressed.  I waited a very long time again.  When they came back, I went through my list of questions.  She has a year and a half of experience working with trans-patients (really?!!), and does chest masculinizing surgeries a couple times per month.  She requires patients to be off T one week before and one week after surgery.  50% of patients will immediately retain nipple sensation, and 80% will eventually over time regain sensation.  She could not show me any examples of her work that would be related to my surgery type.  She could not tell me how much it would cost, not even a ballpark estimate.

Before leaving, I gave her feedback.  I told her how I had been misgendered by the staff.  She conceded that they needed to work on that.  I also, in front of the students, said, “As someone who is transgender, I have gender dysphoria around my naked body.  These may not be the best types of appointments to have students present.  It felt like I had an audience, and I didn’t feel comfortable being partially exposed.”  She responded, “Thank you for that feedback.”  I understand she might not have control over when she has interns with her, but she could CERTAINLY ask for consent, or ask that the interns not be present for the naked part.  I wanted to give her more personal feedback, such as, “It’s not appropriate to comment on my body,” but in the end I didn’t go there.  I just couldn’t right then.

This surgeon and the staff could benefit from some trans-related training, particularly to the sensitivities trans-people may feel about their naked bodies, specifically chests.  Make it short and sweet!


Top surgery consultation #1

I traveled to Ardmore, PA and met with Dr. Rumer yesterday.  The consultation went well overall, and it’s prompted me to start looking at lots of top surgery photos online, something I’ve done in the past, but without much of a framework or focus.

She’s located in a college town / upscale suburb of Philadelphia, and her office / house(?) is a white brick old Victorian creepy looking place.  Very apt for visiting 2 days after Halloween.  There is street parking, and you have to get buzzed in.  I was envisioning a medical center of some sort, but this place had the vibe of a hair salon – everything was whites, greys, and black, very sleek and futuristic looking.  The receptionist offered me something to drink.  I arrived early and was seen by the nurse practitioner right away.  She also offered me some water or coffee.

We went over my medical history I had filled out online in advance.  I guess I forgot to add in testosterone under “medications,” and she understandably assumed I wasn’t on T.  When I said I am on a low dose, she added that information.  (Being on T is NOT a requirement for getting top surgery.)  She also asked about how I identify, if I could provide a letter from a mental health professional (required), if I have legally changed my name, am I out to everyone in my life, and how long have I gone by male pronouns.  There were no issues or clarifications with any of my answers: That I am not FTM, I identify as non-binary, I can get a letter, I have not legally changed my name, I’m out to everyone except work, and I’ve gone by male pronouns for close to 10 years.  (That got a “wow” out of her, haha.)  I’m glad she didn’t ask me about gender dysphoria or how I felt about my chest, because I wouldn’t have known what to say / didn’t have a statement prepared.  Even though it seems like if I’ve made it this far, I should be able to articulate that!!!

She made sure I understood that I would be putting on an oversized paper vest momentarily and that Dr. Rumer would be looking at my chest.  Was I OK with that?  I said yes I expected as much.

She said she’d be back with Dr. Rumer, and gave me a moment to put on the vest.  They re-entered, Dr. Rumer said, “Nice to see you again.”  (Presumably because I’d said I’d heard of her through the Philadelphia Trans-Health Conference, although I didn’t go to any of her presentations or actually meet her.)  She looked at my chest for literally one second (I’m glad it was so brief) and declared I could go with peri-areolar if I wanted.  Is that what I wanted?  I said yeah, probably.

From there, she showed me a few slides about what to expect, and she showed me two before and after pictures.  The only disappointing aspect of this appointment was I asked her, “Do you have more pictures?” and she replied that she doesn’t really because they are all the same.  I was pretty dissatisfied with that – it gave me the feeling that these were the two best that she had hand picked to present.  I would have liked to see a dozen examples of peoples’ chests; there aren’t that many online.

Other than that, she was very friendly and personable and she answered all my questions thoroughly.

  1.  What are the odds of retaining nipple sensation?  Only less than 1% will not retain sensation.  (Those odds seem too good to be believed; I’m not sure I totally believe her!)
  2. How many appointments are required?  A lot!  One a week before surgery, one a week after surgery, then a few at different intervals (I can’t remember) and one at the one year mark.  For people out of town, most of them can occur over skype if everything is going smoothly.  The only necessary travel is for the surgery itself, then a week after, and then a year after.
  3. Do you have to go off T before surgery?  Yes, you have to be off T 2 weeks leading up and 2 weeks post-surgery.  Why is this?  Because of risks of excess bleeding.  I feel resistant about this and still don’t quite understand, but I’ve heard it before and would have to accept it.
  4. How long can I be out of work?  I have a very physical job.  She would write me a letter to go back whenever I want, especially since I have sick time accrued and wouldn’t be on disability.  I’d probably look at 6-8 weeks.
  5. Do you resize nipples?  She resizes areolas, and nipples retract on their own.
  6. The total costs she quoted me, including staying 2 nights in her office(?) / home(?) / guest rooms is $7,480.  That seems on par with other surgeons, maybe a little on the high side.

I have another consultation on Thursday with a local surgeon.  I will be curious how the two compare.


Moving forward with the process of getting top surgery

I have two consultations within the next two weeks with surgeons.  I can’t believe I made it this far – I didn’t always know I would get top surgery.  Even now, I’d say I’m about 99% certain, but I’m still hesitant to talk about it or write about it.  I’ve never written about it here other than just quick, vague mentions.

There were some hang-ups I had to work to get past (and I’m still working through) in order to allow myself to feel like I can do this:

It is a want, not a need.  I don’t need this – I’d say it’s been a persistent nagging feeling for years and years and years, but never an intolerable feeling of disgust or revulsion.  If my chest is not a source of gender dysphoria in a way I can’t live with, can I still get top surgery?  Yeah, why not?  It will definitely improve my quality of life.  Throughout adulthood, I have fantasized about wearing t-shirts or tank tops in the summer, without a binder.  I avoid binders when I can, which leads me to another hang-up…

My chest is small.  My chest is so small that it seems like I could just live with it how it is.  Can’t I just live with it?  It’s not cumbersome; I don’t have to do much to hide what I have.  In the winter, it’s not much of a problem.  I can just layer and I don’t have to bind.  In the summer, I think about it all too much.  Sometimes I bind; other times I just attempt to layer and be hot.

Ultimately, my chest doesn’t look how I think it should look, and if I have the means to change that, I don’t see why I shouldn’t.  Urgency (and my lack thereof) plays a role in whether I think I get to do this, but I can get over that.  I think.  I have a lot of shirts I’d like to wear, but don’t.  Because they don’t look right.  I spend a lot of time thinking about how my body could look different.

For a very long time, I thought I would get top surgery one day, but I had no idea how to make a first step.  Which just tells me I probably wasn’t ready yet.  It seemed so daunting as to be impossible.  Finally, this summer, I was corresponding with a trans-guy I know locally, and he said he got surgery in our city.  That blew my mind – I didn’t know there was anyone here.

I started looking at a Facebook group where others had written about their experiences with her, and I could suddenly wrap my head around moving ahead.  I called and booked a consultation for a month away.  As soon as I did that, more doors opened up.  I could suddenly envision traveling, meeting with other surgeons, all the stuff involved in getting top surgery, usually.  I did minimal amounts of research (I already know a bunch of surgeons by name – I’m sure I will do more research.  It’s going to be a long process) and called Dr. Rumer’s office, about 5 hours away.  I’ll be traveling just to meet with her.  That seems huge.  She waived the consultation fee because I have been to the Philadelphia Trans Health Conference, one of the many places she presents at.  That’s pretty cool.

These consultations happen to be only 3 days apart – it’s going to be a busy week, coming up.


Thoughts on getting a diagnosis

Last week in therapy, I talked briefly about planning ahead for top surgery one day.  I said that I might want to do this, maybe as early as this coming summer.  That’s the most concrete thing I’ve ever said about the subject.  She asked what some first steps would be, and I replied, “look into whether it would be covered by my insurance.”  That’s kinda something that would really help frame it in my mind, the answer to that…  She asked me how I’d do that, and I really floundered with the actual words I would use if I were for real making a phone call to insurance people.

It’s too sensitive and too hypothetical in my mind still, and I could barely even say, “female to male chest reconstruction surgery” out loud, just to her.  She got it and said, “what you could do is find out the code for that type of surgery, and when you make the call, you can just ask about the code as opposed to using the words.”  I said, ok, yes, I think I could do that.  She said she would look it up for me and email me the code.

She ended up finding out a ton more info than just the code, on her own.  She said certain info led to more questions and she ended up just calling.  Basically, she got all the information for me, for which I am so grateful because it would have felt too emotional for me to do on my own, at this time.  It is NOT covered by insurance.  I’m not surprised.  I told her that doesn’t change much – I’m still considering it.

We briefly talked about it again this week, and about gender identity in general.  She said that some surgeons require a diagnosis of gender dysphoria for X amount of time in advance (glad she is doing the relevant research!), and should she be diagnosing me with that?  This turned into a heated discussion (on my end), with the conclusion that I do not care about that, but I am OK with that, if it’s in order to help along a process.  And that, again, I don’t really care to know what she is doing in that regard.

The idea of being diagnosed with a mental health label is contentious in my mind, and she knows this.  She gets it.  I’ll be writing about this further in my next blog post, probably next week.  A teaser for what is to come:  I was misdiagnosed with bipolar disorder at the age of 17, and held onto that belief strongly for about 6 or so years.  That’s a heavy duty label to be grappling with, unnecessarily.

My therapist is not a gender therapist, but she is doing right by me more than any other therapist I’ve ever had (and some have been gender therapists).  There was a time where I thought – we both thought – I would need to go to a different therapist in order to progress with any medical transition steps (I did this in order to access testosterone, kinda unnecessarily in the end).  I don’t think that anymore.  Why can’t she be that person?  I think she is getting on board with, she can be that person.  We concluded recently that a big goal for therapy is to make some progress with transgender-related issues and decisions, and I said I would send her some more general information to get her started.  I sent her the following resources:

Genderqueers, Gender Rebels, and OtherWise in the National Transgender Discrimination Survey

Trans Research Blog – a compilation of what is out there

Trans Bodies, Trans Selves – a great book to have on hand

Anyone have other essential resources?

More than once, she has said, where is the data?  Where is the research that says this and this and this are best practices?  And I just keep responding, There needs to be more research.  And I just keep shrugging.  IT DOES NOT EXIST.  (Yet.)  I don’t know whether she believed me initially, but she may be starting to realize it by now.  It’s maddening how little is out there.

Do I think that I have gender dysphoria?  Whoa.  That is going to take way too long to pull apart right now.  That’s probably for a future post!  Do I mind being diagnosed with that for the purposes of having a wider selection of surgeons to choose from if I do decide to move forward with top surgery?  Not at all!  It’s close enough.  (Although I do strongly, strongly wish more surgeons would get on board with the informed consent model.)

Edit:  Now that I think about it, I’m sure I’ve already been diagnosed with gender dysphoria by my primary care physician (for my testosterone prescription) and probably at least one other therapist.  To me, it all feels so arbitrary.


From whimsical musings to invasive ruminations on transitioning

For over a decade, I had been going back and forth hundreds (thousands?) of times in my head about whether transitioning was right for me or not.  Or if not every aspect of it, what about this but not that?  Will I ever move forward with some aspect maybe?  At some point not that long ago, I seemed to come to the conclusion that no, I wasn’t going to move forward because if I were, I would have done something about it by now.  And I haven’t, so I’m not.  I must be lacking some internal drive, so it must not be something that I need to do.  I settled on identifying as genderqueer and trans* but not planning on medically transitioning in any way.  And I seemed satisfied with that.  (?)  But not quite, or, no, not at all actually.  Because it was still on my mind.  Sometimes just as whimsical musings in the back of my brain.  Other times as pervasive/invasive body-dysphoric consistent ruminations.

I guess I always thought that if I did move forward with something, it would be top surgery, and not HRT.  Because I never want to consistently pass as male.  I want to continue looking androgynous forever.  Top surgery could help with that (although I’m fortunate in that I can get away without surgery, and without binding, in hiding what I have).  Taking testosterone would be going further than I want to go.  So I thought.

I thought it had to be all or nothing.  I thought I had to have a case ready about how I need to transition, in order to access testosterone.  And I don’t need to transiton, and I really don’t like to lie.  I thought I would need a letter from a therapist, and to jump through all these hoops, to access testosterone.  And I wasn’t even sure I wanted it!  Eventually I reached a point where I just knew that I needed to try it, at some point, just so that I could know.  So that at the very least, I could think about it differently or think about it less often, as it relates to a decision about something I should or should not do.

I have this awesome therapist.  She doesn’t know much about trans* identities.  I’m fairly certain she had not previously had a trans* client before, although I could be wrong.  I’d been talking to her about this stuff, and she’d been following along, more or less, in stride.  When I would say I need to try this out, she would say, “then why not!”  I asked her if she’d write me a letter if need be, and she said she wouldn’t be comfortable doing that; she doesn’t have enough knowledge about it.  Still operating under the assumption that I would need a letter, I started also seeing another therapist, basically for the purpose of getting a letter.

This second therapist gave me the name of a doctor during our first session.  Turns out that, apparently, I didn’t need a letter!  Turns out I didn’t need to convince anyone at any point that I wanted to transition medically.  I never once had to lie to get my hands on testosterone.  And once I did get my hands on it, I was given the freedom to experiment with the dosing, basically use as much or as little as I wanted.  Turns out I want to use as little as possible.  Turns out I might be able to stay on it for the rest of my life without looking any more masculine than I currently do (this has yet to be proven, but it’s been 6 months now, and so far, so good).  And the internal effects, with this super low dose, are significant and pretty much better than I could have even hoped for.

Basically, for all those years of wondering and second-guessing and processing and feeling anxious and obsessing and daydreaming and doubting myself and ultimately sort of concluding by default that I wouldn’t take any steps forward, actually doing something about it has been one of the best decisions I’ve ever made.

And in retrospect, it isn’t like there’s no turning back, to some extent.  Testosterone is a slow-moving substance in terms of long-term changes… I’m really enjoying the internal forward momentum though.