***From TerraNet, San Juan Capistrano, CA (714) 248-2836 TRANSSEXUAL GUIDE A J2CP Pamphlet The historical records of human behavior clearly indicate that transsexualism existed long before it found a name. But until modern medicine recognized, defined, and developed therapies for this condition, the transsexual was left to cope with his1 difficulties by more or less unsatisfactory, and often tragic, means of his own devising. The individual whose firm conviction that the sex which his body expresses contradicts the sex to which he feels himself to belong need no longer resign himself to this predicament. Skilled professional help is now available to him, help that is given with understanding and free from false moral judgments. The course of sex reassignment is a complex one, involving many physical, social and emotional readjustments. It is an ongoing process, of which surgery, while it is the culmination, is but one of many essential elements of transformation. Once your physician makes a diagnosis of transsexualism, he will require, and you should require of yourself, that the way toward surgery be carefully prepared, in order to eliminate possible practical problems and embarrassments, and the more serious possibility of belated doubts, which might otherwise arise after surgery has been performed. Even after the successful completion of surgery, certain physical and emotional precautions must be taken, to ensure your continuing health and well-being. The forgoing reminders were not set down to discourage you from seeking help, but with the object of promoting a realistic approach to therapy. Most instances of difficulties in post-surgical adjustment to sex reassignment may be attributed to careless or insufficient preparation. On the other hand, physicians report marked success in the vast majority of cases where preparation has been intelligent and thorough. This booklet is designed to inform you s to how you may best help yourself, and obtain the best possible help from others, in building a new life. SELF HELP THE TRIAL PERIOD No part of your preparation for sex reassignment is more important than the first-hand experience of dressing, working, living in the desired gender role for a continuous and considerable period of time prior to surgery. Most gender identity clinics, and many physicians in private practice, require from one year to two years of constant 24 hour a day cross-gender experience before recommending a patient for surgery. --------------------------------------------------------------- 1 Masculine pronouns are used throughout, unless the genetic female is referred to specifically, for the sake of clarity. --------------------------------------------------------------- This may seem an excessively long period to you before you begin, but experience has shown that no other test is so effective in preventing the tragedy of a wrong decision for surgery, the results of which are irreversible. On the other hand, there is no better means of laying the groundwork for every aspect of your new life, and strengthening your confidence for it, than this preparatory period. It will be helpful to review two typical cases in which people who considered themselves transsexuals decided against surgery as a direct result of their cross-gender experience. A married man who occasionally wore women's clothing when he accompanied his wife to nightclubs, and who found intercourse more pleasurable when he dressed in feminine lingerie, began a trial period in which he lived alone and wore feminine clothing consistently. One evening, he picked up a man and brought him home. Far from finding sexual relations more satisfying, as he had expected, the experience was very distressing to him. Later he found himself missing his wife, who was sympathetic to his intermittent desire to cross-dress, and the life they shared together. Finally, he returned home with relief, thankful that he had not taken prematurely a decision that could not be reversed. Counselors should recognize that this man was not a transsexual, but a transvestite, whose final decision reflected a realistic adjustment to that condition. Another man, who lived with a male lover decided to prepare himself for transsexual surgery. He was of slender build and, with his delicate features and tasteful grooming, presented the appearance of an attractive young woman when "dressed." It was necessary for him to leave his high-salaried professional job, and he found employment as a secretary in the same field, with considerable loss of income and of the mental stimulation he previously enjoyed in his work. This man was accepted completely as a woman, socially in his office, and on the street, where he attracted many admiring glances from men. Yet he decided that surgery was not for him. Why? As Bill tells it, "This is definitely a mans's world, whatever they say about Women's Lib. I just couldn't get used to that condescending manner most men have toward women. If I offered an opinion to any of the bosses at work, even on a subject I knew a lot more about than they did, they either ignored me or let me know that I was out of line. At a party, when the men were talking about something that interested me, it was the same thing. And if I saw a man there who attracted me, he backed away if I took the initiative." "And of course living on so much less than I was used to and counting pennies was hard to take. And all because I wore skirts! When I went to see Dr. X, I wanted to operation right away, and I couldn't understand why he insisted I give it a trial first. Now, am I glad he did! Surgery would have been a terrible mistake for me." Bill has found himself a new job at his original status, and accepts his homosexual nature and relationships more fully than he ever did before. Apart from winnowing out those who would not benefit from sex reassignment, the trial period serves several positive functions for those who would. No matter how powerful your personal conviction that you are trapped in the body of the wrong sex, nothing can reinforce your confidence in this conviction as effectively as the experience of being treated as a member of the gender of choice -- all day, every day, by everyone you meet. Continuous daily practice in the new role, socially and at work, is essential for the development of the habit patterns and the inner assurance that will evoke this gratifying response from friends and associates. As certain as you may be of your inner identity, and even if many of your behavior patterns already conform to it, there are likely to be a number of subtle ways of expressing gender -- for example, choice of words, and loudness or pitch of laughter -- that only observation and practice can perfect. Furthermore, some of the social adjustments that made problems for Bill may at first trouble you to some degree, until you find a way to live with them. It is essential, then, that the cross-gender trial period be long enough to allow you to overcome awkwardness, establish new behavior patterns, and approach unfamiliar situations with an unforced inner confidence. If you have achieved this, the moment will have arrived for surgery to confirm the bodily changes for which you have so well prepared. Yet, perhaps as many as 90% of people who, at one time, were totally and strongly convinced that surgery was THE answer change their mind -- not necessarily because of a psychotherapist, but because the real life experience of trying cross-living proved to not be the answer they were seeking. Hopefully, of course, this change of mind occurs BEFORE irreversible surgery. PREPARING YOURSELF Younger transsexuals generally have an easier time than older transsexuals in easing into the new role, since their peers tend to be more accepting and to hold more generous and flexible concepts of gender identity. In addition, people in a more advance age group usually have more at stake, emotionally and economically, in making the change. They may have to disentangle themselves from marital commitments, and sometimes they will have to forfeit an advance career, with the higher income and the professional status to which they have become accustomed. It is also true that our masculine and feminine habits become more ingrained with time. Moreover, transsexuals, such as teachers, whose jobs require them to work under the public eye, may even have over-compensated (i.e., exaggerated their manner and dress to conform with their officially recorded sex) as a form of protective camouflage. This is not to say that modes of behavior cannot be altered later in life. It simply means that the older transsexual may have to work a little harder and longer than may his younger counterpart. Many gender identity clinics require that the older transsexual have a longer real life trial period (2-3 years) than the younger patient. This is often very necessary and important even though the older patient often feels that because his time "is running out" he should be granted surgery even faster than the younger patient. It is not advisable to postpone your testing of the new identity until the hormones administered by your physician produce adequate physical changes. Like an actor preparing for a new role, hold our rehearsals in private, consulting your mirror and perhaps using a tape recorder, and then try several dress rehearsals before holding your first public performance. A close friend or friends, visiting with you for an evening at home, might be your first audience. For your next effort, you might arrange to spend a weekend away from home with a friend, going out with him in cross-dress only in the evening. When you feel more fully prepared and confident--and this is a moment only you will recognize--take a walk in daylight in a public place. You will know that your performance is successful if no one you pass turns to take a second doubtful look as you go by. The idea, basically, is don't burn bridges until you are absolutely sure you won't need to get back. (Remember that as many as 90% of self-diagnosed transsexuals do change their mind, and every single one of them would probably have been angry and insulted if anyone had dared suggest that they might change their mind--that is, until the real life cross gender trial period showed them with their own eyes that changing sex didn't solve the problem.) Not burning bridges here means that the patient should first cross-dress in private, then in front of close and accepting friends, then in front of strangers (try the shopping center in the next town where you won't be recognized in case you just aren't convincing enough yet), then closer to home--before announcing to the world (family, friends, neighbors and coworkers) what you are preparing to do. It is sometimes a tragic mistake to lose family and job by prematurely dressing in public, and then finding out you just can't make it, or don't like it, in the new gender role. It has been observed that some male-to-female transsexuals tend to over-do in makeup and dress. It is always advisable, when you are uncertain, to understate rather than exaggerate your appearance, which might otherwise attract undue attention. If you are now fairly sure of yourself, but still have some doubts, you may decide to take a course in grooming. This, too, may be accomplished during the trial period. A charm or model school can offer good guidance in helping you to polish your mannerisms and in providing tips on behavior in various social situations. (Beauty schools usually limit their instruction to hair-dressing and makeup techniques; they will not be as useful for your purposes.) In enrolling in such a school, use your judgement about confiding in the director. As with people in any walk of life, some may be unsympathetic and reject your application, while others will be more cooperative, and perhaps arrange for you to be instructed privately. Above all, realize that most people will take you at face value without speculating about your sexual status, especially if you are not apologetic in your manner. You can reinforce this awareness by taking note of how many hairy, muscular women and how many beardless, somewhat feminine-appearing men are unquestioningly accepted as members of their genetic sex by the people around them. Few individuals physically approximate the masculine or feminine ideals of the magazine ads and television commercials. The key to being accepted by others is your own self-acceptance. Remember that the confidence with which you approach them will be the determining factor in their response to you. In a later section, we will discuss the physical changes achieved through hormone therapy, which you will be receiving during the preoperative period. You will find these changes highly beneficial in reinforcing your confidence and your acceptance by others. ADDITIONAL TIPS Hormones will effect some important physical changes during the preoperative period, but there are other steps you will want to take to improve your appearance in the new role before surgery. [Female to Male tips not transcribed. LH] Male-to-Female Transsexuals The penis may be concealed by bending it backward toward the anus and securing it with surgical or masking tape or gauze, covered with a kotex pad. A girdle is then worn to secure it in place. Loose pants or shirts will help hide the crotch. Avoid the use of public restrooms whenever possible. When this is not feasible, always urinate in a seated position in a locked cubicle. If you stand, your head may be seen over the top of the door, or it may be noticed that your feet are pointed toward instead of away from the commode. POSITIVE ATTITUDES Other people can be of assistance to you in many ways during your transition to the new role, particularly if their help is intelligently sought and gracefully received. Experience physicians will provide the essential medical care. An understanding friend, relative or employer, even if you know only one such person, can offer invaluable moral or practical support. Some physicians and counselors who specialize in treating transsexuals schedule regular group meetings in which their patients meet to discuss their mutual problems and benefit from shared experiences. But it is a mistake for anyone to depend solely upon others for help in surmounting his problems. Indeed, if it becomes apparent that we are not meeting our friends at least half way, by showing initiative and courage on our own behalf, their inclination to be of help may quickly diminish. "Why me?" is the question so often asked by people in trouble. Perhaps it is a question which at first one cannot avoid asking. But nothing is more certain than that no one hold the key to the inequities of human fortunes -- why some of us suffer material want while others are over-endowed with the world's good, why some have a greater share of physical beauty and others less. WE must all ultimately acknowledge the futility of such questions, accept our circumstances, and go on energetically from there, doing the best we can with what we have, without a chip on our shoulder that just turns potential new friends off. Whatever our religious beliefs, or lack of them, the Book of Job tells the story that for as long as Job persisted in lamenting his fate, his troubles, which at first seemed so great they could grow no worse, grew greater still. when at last he came to the end of lamentation, and accepted himself and his circumstances, he found in himself the strength to rebuild a life that had seemed ruined beyond repair. Although other people can help us, as we can help them, each one of us must learn to look inward, to discover his own resources and to depend primarily upon them. Those of us who enjoy a faith in God, or in a reality that transcends the personal, may find strength in this belief; but even this orientation may not be one of utter dependency. Most religious philosophies embody the awareness that "God helps those who help themselves." How we regard ourselves suggests to others what their attitude toward us should be. If the transsexual persists in thinking of himself as essentially crippled, in a physical or emotional sense, it is probably that this feeling will infect others in their reactions to him. If, on the other hand, he more realistically regards himself as an individual with problems which can be remedied, and actively applies himself to obtaining the help which is available to him, this constructive self- acceptance will stimulate in other people an enthusiastic response that will reinforce his own efforts. negative thought patterns can be as damaging as negative actions to the person who indulges in them. Learn to divert yourself from the self-destructive mental repetition of your problems by turning your attention to some constructive activity the moment you become aware that your thoughts are taking a negative turn. Arrange to meet a friend or pick up a good book. Learn some simple handicraft, like crewel work, for example, with which you can quickly occupy yourself at difficult moments. There can be unusual gratification in using your own misfortune to help you grow in compassion toward others who may be even less fortunate than you. Make a virtue of the common necessity of working at a job to discharge your medical and living expenses. During the hours in which you apply yourself to your work, you will generally be too busy to drift into negative thoughts. Remember that no matte how humble the work you do, it produces a product or serves a need, and the salary you earn each day carries you closer to your goal. In summary: Your personal program should be one of constructive thought reinforces with constructive action. PREPARING OTHERS One important way in which you can smooth the path for yourself is to carefully prepare those with whom you are closely associated for the changes to come in your life. Except in the case of those friends and relatives you are fairly certain will be inclined to support your decision, it would be wise to postpone discussions until you are well along in the trial period and you and your counselor are in agreement that you have made the right choice. It cannot be too strongly stressed that it is in your own best interests to approach others with the utmost tact and forethought when the time comes to talk over your plans. Professionals who have worked with transsexuals can cite numerous instances in which families and employers have been shocked and alienated on seeing a familiar person abruptly appear before them in unfamiliar guise, when at least in some cases, a sensitively prepared discussion before he appeared in cross-dress would have kept a family united, or saved a job. There are families which, when carefully approached, surprised their son or daughter by being far more sympathetic and helpful than could have been anticipated. Similarly, it is not uncommon for a transsexual to be accepted in his old job after surgery, or assisted by his boss in finding new employment, after a frank private conversation about his plans. Many schools will readmit a student, correcting his records so that they carry only his new name and sex, or help him to gain admission to another school with no loss of scholastic credit, upon tactful application to the appropriate officials. If you are married, and especially if there are children, the situation is in some ways more sensitive. You are then concerned with the person or persons with whom your life has been most intimately related. Reactions will vary, according to the quality of the relationship with spouses and children. A husband or wife probably will not taken completely by surprise, but he or she may need some professional assistance in reorienting his life. You will no doubt choose to obtain a divorce, and the surgeon will require this before undertaking surgery. Where children are concerned, one should proceed with delicacy and care. It may be advisable to postpone a full discussion of the facts of your situation, if the children are adolescent or of pre-school age. A child in grade school, by which time gender identity is well established is less likely to be disturbed. However, you will want to consider the likelihood that he will discuss the matter with his peers, who may react adversely or make your private concerns common knowledge in the community. A counselor should be used to help assess the child's readiness to hear the truth, and his or her reaction later. The child's age and maturity should be carefully weighed before deciding whether or how fully to take him into your confidence, and one or two meetings with a professional counselor may greatly assist you to fulfill this parental responsibility with intelligence as well as love. When you separate from your spouse, and if the children remain with him/her, remember that they will continue to need assurances, through your letters, phone calls and visits, of your continuing interest in their activities and their welfare. To sum up, it stands to reason that you will be serving your own best interests by considering the feelings of others, and not, through thoughtlessness or a self-defeating defiance, risking severed relations with those people who may be of real help to you if they are approached with tact and care. 2 MAKiNG IT OFFICIAL 3 When the probability of sex reassignment surgery is 2 When talking over your plans with family or friends, you may find it helpful to offer them a copy of The Janus Information Facility booklet: INFORMATION FOR THE FAMILY OF THE TRANSSEXUAL/ 3 Throughout this section, the services of an attorney are frequently recommended. If funds are limited, your local Legal Aid Society may provide assistance for a token fee. While it is true that in delicate situations, and sometimes in dealing with bureaucratic officials, the intervention of a lawyer may be helpful, many of these procedures can be successfully handled on your own. The Janus INformation Facility booklet, LEGAL ASPECTS OF TRANSSEXUALISM, treats in full detail the matters discussed in this section, and is available on request to you, your attorney, and concerned governmental and social agencies. imminent, you will want to begin to establish a new public identity. There are a number of legal and administrative processes which you may use to your advantage and to prevent harassment, both during the preoperative period and after surgery. You may not be aware that under the common law you have a legal right to call yourself by any name you wish, provided there is no intent to defraud or of prejudice to others. If your name applies to either sex (e.f. Chris, Leslie), it may be advisable to continue to use it. Otherwise, it would be expedient to select a name with the same first initial. You may use your new name when applying for a library card and museum memberships, when establishing a bank account or applying for credit cards: all useful items of identification. Many of these procedures may be handled through the mails. For example, you may open a new bank account without closing out the account under your original name, and conduct the transaction by mail. Then, at a later date, you may write a check to your new account from the old one, withdrawing all funds and thus closing the account. In opening a checking account, a friend or your attorney can provide a credit reference. During the transition period, when mail will be arriving in the names of both sexes, it might be advisable to rent a Post Office box in order to avoid embarrassment. Once your new name is firmly established, you can revert to receiving mail in the usual way. There are several safeguards you may take to avoid running afoul of the law. The first precaution is to favor conservative rather than flamboyant dress, so that you will not attract unfavorable notice. Second, you may obtain from your physician or counselor a letter to the effect that he is treating you for a transsexual condition, and that you are cross-dressing on his recommendation. The counselor may supply to you an identification car which includes the following data: your counselor's name, address and phone number, and the information that he is treating you as a prerequisite to sex reassignment surgery; a statement that you are required to live in the gender of choice for 12 months or longer prior to surgery; your height, weight, eye color, and the date of birth; and that additional information, if needed, is available from him. Your name (both of them) and address should be included. It is advisable to provide yourself with whatever record changes and documents are available to you; this will enhance your sense of comfort and security in the new gender role. The letter from your treating counselor and a court order for a legal change of name are the most helpful of those obtainable preoperatively, as the new birth certificate will be after surgery is completed. The methods for securing these official documents, which can be useful in helping you to acquire still other documents, will be discussed in detail below. Whether you are applying for new documents of identity or requesting correction of those you already hold, you can help yourself by being neither over-aggressive nor apologetic. Remember that you are within your rights in making use of these procedures, and that an attitude of quiet self-confidence will get the best results. LEGAL PETITION FOR CHANGE OF NAME As previously noted, a change of name by court decree may not be necessary in most cases. In general, because of the costs and the possible loss of privacy, it might be wise to avoid litigation. In some situations, however, as for example in claiming a legacy, a prior change of name by court decree may be a convenience, if not a necessity. Several different methods have been successfully pursued by transsexuals in petitioning for a change of name. Some involve legal help, and others may be accomplished directly by the individual himself. Some of thee procedures known to us will be outlined below. It should be borne in mind that the venue of the court and the attitude of the presiding officer are often decisive factors in the success of your petition. It would be advisable, therefore, to inform yourself about these to the best of your ability before choosing your method of application. A postoperative transsexual employing the services of an attorney will find that the following procedure is commonly successful. Request that your physician send to the attorney a letter confirming that sex reassignment surgery has been performed, recommending the change of name which will reflect your changed anatomical status, and further stating that the name change is vital to your health and well-being. This is the essential document in your attorney's presentation to the court. If the court then determines that there is no evidence or intention of fraud, your petition should be granted. It should be noted that the court's decree in granting a change of name is not accepted as legal proof of a change of sex. However, possession of a court order for a change of name often assists in the process of changing sex status, as well as name, on the birth certificate. This is much more easily achieved by the postoperative transsexual, because of the medical documents he presents, but some preoperative transsexuals, on presenting the court decree of name change, also have been successful in having sex status altered on the birth certificate. Usually however, sex status cannot be changed until after surgery. In some states, the following simple procedure has been followed with good results by both pre- and postoperative transsexuals. Application for a change of name is made, for a fee, and appropriate forms are filed with the Clerks Office of the local Probate, Surrogate, or Superior Court, no other action being required. When changing your name, it is advisable, for practical reasons, to retain the last name unchanged. IN CASE OF ARREST If you are taken into custody for cross-dressing or another complaint related to transsexualism, remember that you are not obliged to supply an information other than your name, address, date of birth, and social security number. Other questions need not be answered without the presence of an attorney, and you would be well-advised to volunteer no further information. Even seemingly innocent remarks may later be used against you. Be sure that the data you supply (name, address, etc.) is truthful. Giving false information is grounds for prosecution on the charge of obstructing an officer. The arresting officer must inform you of your constitutional rights to remain silent during interrogation. Information obtained without the issuance of a warning cannot legally be used against you. Do not wait until the time of trial before requesting legal aid. You are entitled to call an attorney even before preliminary questioning (i.e., name, address, etc.) begins, and it is recommended that you do so. Once the intake process is under way, the authorities have the right to check your record and you may find it helpful to consult with an attorney before supplying any information. He can also provide substantial assistance during the pre-trial hearing in the District Attorney's office, when he may be successful in having the case dismissed or the charges against you reduced. A lawyer also will be helpful if you have been subjected to police brutality during the arrest or while in custody. We know of several such actions which have been successfully filed, and damages collected, on the attorney's petition for a trial judgement. If you should be held in custody pending trial, or if the trial judgement whether for a complaint related or unrelated to transsexualism, goes against you, an extended period of confinement raises problems of evaluation and treatment. Most prisons and jails will not start or initiate counseling or hormones if you were not already on them before going to jail. Only some jails will let you continue hormones if you were already on them, and very few jails will help with any arrangements leading toward surgery. Most jails will house you in a single (solitary) cell in the mal or female section depending on whether you have any bodily changes from prior hormone therapy or surgery, and how long you have been living in the current gender role. Sometimes, however, they put you wherever they want to and you may be highly vulnerable to gang rape if housed in a male dormitory! MILITARY SERVICES To date, and to our fullest knowledge, the military services are consistent in their policy of disqualifying transsexuals from enlistment, refusing requests for transfer from men's to women's and women's to men's branches of service, and are discharging, on medical or psychiatric grounds, known transsexuals. A male-to- female transsexual who is contemplating or has undergone sex reassignment surgery usually will have no difficulty in obtaining an exemption from her draft board if she presents a letter from her physician explaining that she is being treated for this condition. Some draft boards may require, in addition, a physical examination. If you are asked to appear before the board more than once, you may wish to enlist legal aid against possible harassment. If, while you are a member of the forces, you reach a decision to undergo treatment preparatory to surgery, it would be advisable first to complete your term of service if possible, in order to avoid a prejudiced discharge, and so that you may qualify fully for the veterans benefits you have earned. Transsexuals who have served in the military prior to treatment and surgery do not forfeit G.I. Bill or other veterans benefits. You will qualify under your new name and sex, all military records and discharge papers being adjusted accordingly, when you submit papers attesting to a legal change of name and your new or amended birth certificate. Veteran's Administration Hospitals have not yet provided preoperative treatment or performed sex reassignment surgery. However, in several cases known to us, they have offered extensive postoperative care, including corrective surgery related to sex reassignment, when required. EMPLOYMENT AND EDUCATION Medical costs for sex reassignment therapy are considerable4. Unless you have substantial private means, it will be necessary to continue earning prior to surgery, and you will want to give careful thought to your vocational plans after surgery is completed. In some cases, where your employer is sympathetic and the work you do is appropriate to your new gender 4 This includes: hormone therapy (pre-and postoperatively), physical and psychiatric examinations, and tests, surgery, and related therapies such as electrolysis, and attorney fees (plan on about $10,000 altogether). Transcription note: This is now said to be up to at least $30,000, today in 1988). role, this will not present a problem, since you may continue to work in the same job or field of work. Others, however, may find it essential to plan for vocational training in a new field. If financial assistance is needed for this, there are sometimes funds available from public sources to which you may apply on your physicians recommendation. Your employer may agree to discharge you from your job, so that you can qualify to collect unemployment insurance. If you judge that it will be necessary to resign your job should your plans become known, be certain to draw all sick leave or sabbatical benefits that have accrued to you, applying them toward the period of cross-gender testing, when you may be short of funds. If you are a licensed member of a trade or profession, you may apply directly to the appropriate state agency to have your name corrected on the licensing documents. However, since the officials concerned may not be well-informed about transsexualism, it may be advisable to make your request through a skilled legal intermediary. Petitions for correction of work licenses usually are routinely granted by trade associations and the accrediting boards of most professions. School boards, however, then to regard returning postoperative transsexual teachers with honest if misinformed concern about endangerment of the morals of their students. They may be more likely to alter the license and reassign the transsexual teacher to duties in another school, if they are approached by a skilled attorney. An attorney can be helpful, too, in presenting your request for job recommendations to former employers, if you anticipate any difficulty in obtaining them in your new name. Most employers, if approached in this way, will be cooperative. If you fail to get their cooperation, and alternative, if you wish to stay in the same line of work, is to apply for jobs subordinate to the one you formerly held, with the confidence that your skills will soon earn you the promotion. Another possibility would be to explain your situation honestly to a prospective employer, if you judge that he may be sympathetic. If you have no trade or profession, these problems ill not arise. You may find it easiest to begin with some unskilled occupation for which recommendations are not needed, or for which a personal recommendation will do: for example, factory work, waiting tables. Most taxicab companies will hire both men and women drivers who have passed the test for a chauffeurs's license. It would not be advisable to apply for a job with a large company, most of which require complete physical examinations of new employees. It would also be practical to attend a secretarial school to study typing, and, if time and money allows, shorthand. Second hand bookshops frequently stock copies of texts on speedwriting (which otherwise are obtainable only through registration for courses in schools which teach this simplified shorthand method) which you can then study on your own at home. There is always a demand for men and women with these skills, and temporary agencies generally require only that you pass their typing and/or stenography tests, without asking for recommendations from former employers. When you are ready, you may decide to return to school for preparation for a more rewarding job. If you already have earned a college degree, or wish to continue your studies, most universities and colleges will be cooperative in changing the name and sex designations on the transcript of a former student. In this instance, too, the assistance of an attorney or social worker can be helpful in insuring a receptive hearing, although direct negotiations with the Dean of Students may be successful, if tactfully undertaken. The federal government makes grants to state vocational rehabilitation agencies "to help them to serve persons with a physical or mental disability who need help in obtaining and holding an appropriate job, and (the grant) is based on (1) the presence of a physical or mental disability; (2) a substantial handicap to employment; (3) reasonable expectation that on completion of services, the disabled person can be engaged in a gainful occupation. "Services include evaluation of rehabilitation potential, counseling and guidance, personal and vocational adjustment, training, maintenance, physical restoration, placement, follow-up and other services." A letter from your physician, addressed to the State Department of Vocational Rehabilitation, should accompany your application for aid. Although transsexualism is not always a recognized disability category, several states have provided assistance to transsexuals under the category of psychiatric disability. The kind and degree of help you may obtain will depend upon several constantly changing factors: the policies of your local Vocational Rehabilitation Office; the individuals who administer them; and the funds available at the time your application is made. This, "physical restoration" may, according to the time and place of application, include courses in grooming and electrolysis for the male-to-female transsexual; and plastic surgery. It should be stressed that, in general, and at the present time, most of the state offices of Vocational Rehabilitation have no clear policy with regard to transsexualism, and many offer little or no help with medical- related therapies. But, since this is a relatively new field for governmental consideration, and the situation is in a state of flux, this is clearly a case of "noting ventured, nothing gained." Do not count on receiving funds for medical help, but, by all means, give it a try. At this time, assistance with fees for vocational training would seem to be somewhat more readily available from this source. MEDICAL HELP FINANCING MEDICAL CARE: INSURANCE If you, like most people, do not enjoy a large independent income, it will be necessary for you to finance your expenses for medical care and recuperation with your own earnings or savings, or possibly through a bank loan, if you are able to offer some collateral. Even surgeons who are testing new techniques in transsexual surgery require full payment for their patients (usually in advance). There is no private foundation, including us, that offers financial assistance for this purpose to transsexuals. For those who qualify for veterans' benefits,, Veterans Administration Hospitals usually provide postoperative care only. A good health insurance policy can be your major source of assistance, but there are several important points of procedure on which you and your surgeon should be informed before you sign the contract and before he applies to the company for reimbursement of fees. Before signing the contract for insurance, read it carefully. Some companies specifically exclude treatment for transsexualism or related conditions from their coverage. Most policies stipulate a twelve month waiting period before providing benefits for conditions which have been diagnosed before you contract for coverage. Therefore, you are well advised to wait until after you have signed the policy before consulting a physician for diagnosis and treatment. Be sure to apply for and sign the insurance contract with your original name and sex (i.e., that which appeared on the first, unamended, birth certificate): if you fail to do so, coverage may be terminated on grounds of fraud. For your fullest protection, re-read this paragraph carefully, to be sure you thoroughly understand these three important points. After you have made a careful choice of insurance policies, have undergone preparatory treatment, and are ready for surgery, it is important that your surgeon be advised of the following information, so that you and he stand the best chance of benefitting fully from your insurance coverage. Claims for health insurance should probably not define the prescribed treatment simply as "transsexual surgery," or as "cosmetic surgery": applications for help under these categories are consistently rejected. Best results have been obtained when the condition (transsexualism) is presented as "a neuroendocrinological or psychohormonal disorder," absolutely requiring and responsive to surgical and hormonal treatment. Another effective classification is "gender dysphoria." Some health insurance policies state that the holder is covered only for "necessary treatment of an injury or disease process." In such a case, the physician should represent transsexualism as "a distinct, medically definable disease entity, for which treatment is required." In every instance, it is advisable for you and your physician to examine carefully the wording of your policy, for indications as to how he should frame his diagnosis. Recently, some insurance companies have become more liberal in providing coverage for preoperative evaluation (medical and psychiatric), sex reassignment surgery, related therapies, and hospital costs. While few companies allow benefits for all these phases, there is a distinct and encouraging trend in this direction. In general, it has been found that coverage is more generously allowed on group than on individual policies, but this is not invariably the case. If you leave the employment of a company which has provided you with group insurance, and which does not exclude benefits for treatment of transsexualism, it would be advisable to maintain the policy on an individual basis. (Although individual policies rarely have as liberal and extensive coverage as the original group policy had.) CHOOSING A PHYSICIAN Until quite recently, the gender identity clinics of university hospitals offered the only facilities for complete therapy, including sex reassignment surgery, for the transsexual. Fees at some of these clinics are high, and the number of people applying for help far exceeds the number that can be accommodated. fortunately, alternative means of treatment are now available. At the present time, many endocrinologists and internists are accepting transsexual patients for hormone therapy, and many surgeons associated with private hospitals now perform sex reassignment operations. For obvious reasons, it is advisable to choose a physician who has had considerable experience in treating transsexuals. Since hormone therapy precedes surgery, you should visit an endocrinologist or internist. At the appropriate time, he will refer you to a surgeon who has performed other sex reassignment operations. In choosing your surgeon, assure yourself as far as possible that he will be interested in vigorously pursuing your insurance claim. However, before you are in a position to seek surgery, and even hormones, it is advisable that you seek a psychiatrist/psychologic evaluation. The Standards of Care of the Harry Benjamin International Gender Dysphoria Association require a psychologic/psychiatric recommendation, based on a complete psychologic evaluation, before hormones can be prescribed, and also require that before sex reassignment surgery, you must be recommended for such surgery by at least two psychologists or psychiatrists (one must be a psychiatrist), at least one of whom has known you for at least six months. The purpose of these visits is not to dissuade you from your decision. It is simply a precautionary measure. Even though this is a required part of the prescribed treatment, you may decide independently, as have other transsexuals, that some sessions of supportive counseling with an understanding therapist will be helpful to you during the periods of transition before or immediately following surgery. If you are experiencing any problems with your employer or your family, they may be more receptive to learning about your situation from a counselor. This the kind of service most physicians are too busy to provide. The counselor also can help you to gain perspective on your situation and provide support and good advice. He may be the objective friend you can use in your corner in times of stress. MEDICAL TREATMENT FOR MINORS For medical as well as legal reasons, surgeons will not perform the sex reassignment operation upon a minor. However, hormone therapy preparatory to surgery is obtainable in certain instances. It helps to have your parents' authorization for treatment, but this is not always required. Some states regard the teenager who is living away from home and providing his own support as an "emancipated" minor, and in these states physicians may cite this doctrine to justify treating a minor at his own request. Many states recently have lowered the age of majority from twenty-one to eighteen, and some legislatures have enacted statutes specifically enabling minors under eighteen to elect medical care. The tendency even in states with no such laws on the books is for the courts to be increasingly liberal in interpreting common-law principles. The urgency and gravity of the case, the age and maturity of the minor, and the doctor's prior knowledge of his medical history are all carefully weighed in such cases. In the past, physicians have exercised caution in treating minors without parental assent because they feared criminal prosecution. Yet it would appear that there is not a single recorded instance of a doctor's being penalized for treating in confidence a minor over fourteen years age, when no surgical procedure was involved. With the increasing liberality of the law and the interpretation of the law, the prospect is that the physician's professional judgement and the minor's request for help soon may be the only requirements for treatment of younger patients. HORMONE THERAPY5 Your physician will prescribe hormones for at least six months before referring you to a surgeon. The physical changes they bring about may enhance your confidence socially, and you may find their calmative effect emotionally beneficial. Should you decide at some point during this trial period not to proceed with surgery, discontinuance of hormones will gradually reverse some of the physical alterations. What are some of these changes? Male-to-Female Transsexuals You may notice that the skin takes on a softer texture. There may be some increase in hair growth on the scalp, although this is less common. After a time, muscular development will diminish somewhat, and there will be a more feminine distribution of fatty tissue: for example, more pronounced hips. The breasts will gradually increase to proportions comparable to those of a girl in the late teens. Larger breasts may be achieved through breast implants, at a later date.6 Hormone therapy will not feminize your voice, but remember that there are women whose extremely husky voices are considered to be both attractive and feminine: Lauren Bacall, Marlene Dietrich, and the late Tallulah Bankhead are notable examples. Speech therapists who work with male-to-female transsexuals concentrate not only on raising the pitch and resonance and softening the quality of the voice; they point out that the use of a more feminine vocabulary, more careful articulation, and a greater range of inflection (rise and fall) of the voice all contribute to a more feminine impression. You may work on these points yourself, with the help of a mirror (to practice freer facial movement) and a tape recorder. If you feel you need professional help, there are speech therapists in private practice, and associated with speech therapy centers in hospitals and universities, who provide special instruction for male-to- 5Some physicians may adopt practices which differ in degree or kind from those outlined here. This section, and those which follow, are intended to give you a general impression of the most commonly followed course of treatment. 6 Silicone implants, the internal placement of plastic- like bags containing silicone jelly, is the approved method of augmenting breast size. There are serious health hazards associated with injections of liquid silicone directly into the breast tissue: it is extremely difficult to detect cancer in the area when the breasts have been augmented by this method; and there is the danger that the injected fluid will move to other parts of the body, causing medical complications. The F.D.A. has denied approval to the use of silicone injections, and you are strongly advised against them. female transsexuals with voice problems.7 Hormones will not appreciably reduce beard growth. Electrolysis of the beard is an essential complement to hormone therapy. You may notice a decrease in libido (sexual desire), after following a program of hormone therapy for some months. Most male-to-female transsexuals consider this to be a helpful modification in adapting to the new role. Also, sperm production may decrease and your fertility (even if you later stop hormones) may be permanently impaired. With few exceptions, transsexuals are required to use hormones throughout their lives postoperatively, in order to ensure maintenance of hormone-stimulated development of physical characteristics of the gender of choice, and for other health- related reasons. However, since the long range effects of hormone therapy are not fully known at this time, it is important That you visit your physician conscientiously every six months after surgery. He can then check on your general health and any possible harmful side effects, providing any required treatment or adjustment of hormone dosage according to his findings. ELECTROLYSIS A course of electrolysis of the beard requires from one to two years of completion8 Before recommending the male-to-female transsexual for surgery, his physician will expect him to complete at least half of this process. There are several important reasons for this recommendation. If, after surgery, when you are now anatomically female in all other respects, there is still noticeable evidence of beard growth, you are very likely to suffer from feelings of confusion as to your present gender. Your confusion may be reflected in the response you receive from others, thus compounding your difficulties. Many physicians experienced in working with transsexuals have noted that serious psychological conflicts 7 A helpful tip offered by one of these therapists is that the transsexual, when introducing herself on the telephone (as, for example, in making an appointment for a job interview) should begin the conversation by saying "This is Miss X." In that way, should she still need some practice in feminizing her voice and if the person on the other end of the line is in some doubt as to her sex, this assertion usually will resolve the equation in her favor. 8 Electrolysis does not permanently discourage hair growth. After the major work has been done, it will be necessary to see your electrologist at infrequent intervals to maintain beardlessness. block the successful adjustment of those patients who have not undergone adequate electrolysis, and who, in their opinion, would otherwise have done well. It is true that a certain amount of time, expense, and discomfort is associated with electrolysis. But it would be most unwise to seriously jeopardize your chances for a fulfilling new life by neglecting to attend to this important aspect of total therapy. You are strongly advised against purchasing one of the electrolysis machines available on the market for self-use. This is an operation which requires long and careful training. If it is clumsily employed, there is a distinct danger of scarring at the site. For this reason, one should also take care to choose an experienced professional operator. If you do not at first have the money or the time to see an electrologist, there are various commercially available wax preparations which you can use at home for hair removal. You will find that this process must be employed every one to two weeks, depending upon heaviness of beard growth. SURGERY Some surgeons prefer to perform the operative procedure for the male-to-female transsexual in two stages. Other surgeons will complete the work in a single process. The male organs are removed and labia, a clitoris and a vagina are constructed. If surgery is performed in two stages (castration and vaginal construction) by two different surgeons, it is important that the two surgeons consult each together before the first stage is undertaken, in order to avoid some possible complications which may occur if the second stage is too long delayed. If cosmetic surgery, such as breast implants or nasal reconstruction, is desired, this is undertaken at a later date after full healing from the initial surgery. The degree of possible sexual pleasure after surgery cannot accurately be predicted. For some, the capacity for orgasm may be lost, but many others report that they are now experiencing it for the first time. In the preferred method of surgery for the male-to-female transsexual, sensitive genital tissue is used to line the vagina and to create a clitoris, thus preserving a degree of erotic sensation, and in some cases providing a small amount of natural lubrication during intercourse. However, when there is not enough penile skin available to completely line the vagina, skin grafts from other parts of the body may be used. There is at present no technique for the transplantation of reproductive organs. Therefore, following surgery, both male-to- female and female-to-male transsexuals are sterile. Married transsexuals have adopted children through social agencies, and the wives of female-to-male transsexuals may choose to bear children through donor insemination. The final results of any surgery cannot be guaranteed by anyone. Scarring, infections, necrosis, loss of skin grafts and disfigurement are always possible, but hopefully occur not too frequently. You should be absolutely sure that before receiving hormones or surgery your doctor explains all of the possible risks to you in words you understand. If you don't understand, ASK -- its your body, and happiness, at stake! POSTOPERATIVE CARE It is essential that the male-to-female transsexual conscientiously follow her surgeon's instruction on the use of the vaginal form9. This is a device designed to keep the vaginal passage open during the period following surgery. During surgery the vagina is packed with gauze. When healing is well advanced the gauze is removed, and you will be instructed to insert and keep the vaginal form in place for most of each day for the first few days of use. After this period, your surgeon will advise you to insert the form several times a day for one or two hours at a time for the next several months or so. Your surgeon also may show you how to lubricate and stretch the vaginal passage twice daily, another important factor in postoperative care. To repeat: these practices which will be explained in some detail by your physician, should be followed faithfully. Failure to do so could result in closing up of the vaginal passage. Be sure to see your physician without delay if, after your return from the hospital, your temperature should become elevated, or if you should experience unusual discomfort or swelling in the surgical area or difficulty in urination. You will be cautioned by your doctor not to use the vaginal passage for intercourse for a period of time following surgery. If you ignore this restriction, there is a serious risk of infection or rupturing of the sutures. When your surgeon tells you that intercourse may be safely engaged in, he will also recommend the most favorable positions which your new internal structure allows. He will also advise you to urinate and empty the bowels before intercourse, in order to provide the maximum space in the vaginal passage for comfort and facility when the penis is penetrating the vaginal canal. Certain easy-to-follow, common sense precepts of health care should be observed postoperatively by both the male-to-female and female-to-male transsexual. Adequate rest is important, and a 9 Some newer surgical techniques eliminate the need for the vaginal form. premature return to work may be ill-advised. The male-to-female transsexual should avoid prolonged standing immediately following surgery, and prolonged sitting may at first be uncomfortable. It is important to keep the weight stable, and especially to avoid any weight gain, so as not to overburden the surgical area. MARRIAGE The question of whether a postoperative transsexual should disclose to a prospective mate that he or she has undergone surgery is primarily an ethical one, but it has legal implications as well. Failure to discuss this matter may give valid grounds for annulment or divorce, in that the marriage may be considered to have been entered into fraudulently. This can affect later alimony, support payments, and division of "community property." The precedent of impotency, which is accepted grounds for divorce in some states, can be invoked by the wife of a female- to-male transsexual. In the case of a male-to-female transsexual, if the transsexual discloses to her husband prior to marriage that she cannot bear children, theoretically her options are open as to whether she also must reveal that she is a transsexual, although presumably if she does so her legal position is stronger in the event of divorce proceedings. Having discussed these problematical legal aspects of marriages entered into by transsexuals, it is important to add that many transsexuals have without publicity contracted enduring and successful marriages which are accepted without notice or comment by other members of the community. Furthermore, they have brought their own children into the marriage, have adopted children, or, in the case of the female-to-male transsexuals, the wife has borne children by means of artificial insemination. CAUTIONARY REMARKS It is likely, as well as understandable, that prior to surgery, while subject to inner stress and limitations of outer circumstances and opportunities, you may have been impeded in the development of your potentials for living a full and fulfilling life. Your interests may well have been restricted by your problems, your energies exhausted by them. If your whole life until then has been centered on the goal of achieving surgery, once it is achieved you may be unpleasantly surprised to find yourself in a predicament comparable to that of the newly retired man who had devoted himself exclusively to his job, never cultivating any outside interests, and now finds himself depressed and at a loss, his life seemingly at a standstill. Now that your life-long problem has been resolved, and after the initial euphoria, you may unexpectedly find yourself facing a void. The obvious answer is to fill it, and without delay. In this situation, some transsexuals find that they benefit from the counseling and support of a sympathetic therapist. Others will begin independently to investigate their world and its possibilities. You will learn to apply newly-released energies to the development of your talents, and to the exploration of the broader range of social relationships and career opportunities now open to you, perhaps for the first time. If, before surgery, the single area of gender identity comprised the whole of your self-knowledge and occupied all your attention, there can be intense pleasure and release in discovering yourself now as a total human being. Another common stumbling block experienced by transsexuals can be the excessive and unrealistic expectations, cherished for many years perhaps, of what life will be like after surgery. Surgery indeed can solve your one major problem, but if you anticipate that it will magically solve all problems, you are due for a disappointment. Life will certainly be more rewarding now. You will be more comfortable, more at ease with you. You can begin to take advantage of many opportunities for self- development and career advancement that were not available to you in the past. But the postoperative transsexual must realize that he has this in common with every other human being, that he too must meet the challenge of all the common difficulties that arise in any life: the occasionally troubled relationships, the possible job frustrations, the temporary depressions and setbacks. Now that you have been relieved of your one consuming problem, you may discover in it one positive aspect that can be uniquely enriching. Having lived the life, however hindered preoperatively, of both sexes, you can enjoy a rare capacity for immediate empathy with people of both sexes, for understanding intimately their points of view and feelings. Where other people may exercise intelligence, imagination and sympathy in their human relationships, you have the additional resource of direct experience of "both sides" of life. If you use this asses, allow the old burdens to fall away, confront life with new curiosity, realism, courage and determination, you can discover, like many transsexuals before you, the unexpected joys of a true rebirth, a more hopeful and better-prepared second chance. ---------------------------------------- Copyright - J2CP Information Services