I have a confession: I am falling apart

Trigger warning….there are explicit discussions of surgical procedures.  There is also some politics.

There is a funny thing about not being busy, and somehow you have even less time.  I am not working at the moment, with no prospects, and while this would be okay under any other time, it is painful during divorce, because there is little to distract me.  Oh.  Well.  Something is.  Transition.

The existence of transgender surgery is such a blessing, I can’t tell you how much.  Thank goodness we have this luxury.  And I can be confident that over time, perhaps generations, what is possible will move forward with great strides.  That has been happening a bit with the changes to insurance law in the USA, where being trans could no longer be regarded as a pre-existing condition and was therefore not grounds to deny coverage.

We can thank President Obama for that.  But in the intervening period, this right has been chipped away at, and although President Biden has tried to maintain protection, the damage wrought by the Trump administration and in individual US states has meant that this is a bit of a lottery, and access to healthcare for trans people varies mightily by state.

But this part of the politics is not what interests me.  It is rather that this change of policy meant that the US went from one of the last places to get transgender surgery to one of the best.  Money has a way of doing that.  And as a result, an entire generation of doctors has grown up able to specialise in this field.

And this is wonderful.  All three surgeons I am considering grew up in this climate.  Right now, I am scheduled with one but have issues with insurance, but the other two are giving me dates too far in the future.  So my choice is to pay the enormous sum of money (from funds which I don’t technically have) and have my surgery or wait for a year and not pay.

That should be an easy to decision.  It should not be so hard to wait, right?  Well, it seems to be.  Although I have been resilient my whole life, for this once, I am not.  I know what suicidal ideation feels like, and what brings it on…a sense of despair, a real feeling of hopelessness.  There is something about crossing that threshold into the world of being a member of our species with vagina that has become so essential to my survival, that I simply cannot wait.

I am scared.  Not just for those reasons.  I am scared of what serious surgery it is, and that I am giving myself a lifelong commitment to a part of my anatomy that will need care in ways that a natal woman’s kitty does not.  I am okay with that.  I am also really, really fascinated by how tissue behaves over time.

Okay, here’s what happens.  If you do the most common type of operation, a “penile inversion” you are using the skin of the penis and scrotum to line the vaginal canal.  They are skin grafts.  First, they heal.  But then, over many, many years, the tissue changes so as to become virtually indistinguishable from vaginal tissue.

The technique which I will be using, involves using the lining of the abdomen to create the vaginal canal.  Essentially, the take a section of it in a second surgery, and without detaching it from its blood supply, just flap it down.  Hence the name.  Peritoneal flap.  It is peritoneal pull-through surgery.  

There are surgeons in Thailand and in the US who are harvesting a tissue which holds the testicles.  It is called the tunica vaginalis.  And had I been born female, this same tissue is what would have lined my vagina and gone up into my uterus all the way to my ovaries.  In other words, it is the same stuff.

Not many surgeons are doing this right now, but essentially they place the small piece of harvested tunica vaginalis tissue at the very end of the vaginal canal, up deep.  It is graft.  You can do this with both the penile inversion (most common approach), but also with a hybrid method using the peritoneal tissue.

I hope this is neither too technical nor too boring.  Why am I talking about this seemingly arcane stuff?  Well, a decade ago, nobody was thinking about these types of things because there wasn’t enough money in transgender surgery.  The grim truth, however, is that this is nothing compared to what is possible.  We are a tiny demographic…transgender people of all stripes, colours, persuasions make up only 1% of the population.  Let’s say that half of us are “male-to-female”…well that cuts the numbers down by quite a lot.  And then, only 18% of trans women end up having SRS (sexual reassignment surgery, aka vaginoplasty).  It is hard to say how many of those who do not do it simply don’t do it because they can’t afford it or don’t have access.

What else?  The waiting lists are so fxxking long.  If a surgeon is really good, whether in Thailand or in the USA, you can count on waiting several years to get a date.  Some people might say this is a good thing.  After all, it is a momentous surgery, life-changing, and you want to make sure that a person has had time to think it through.

In the community, this kind of thinking is gatekeeping, and certainly that is how it has felt to me.  Frustrating.  But we all get our letters, have the psychologists support, the therapy, the hormones, etc.  But this also drives people to take paths towards incompetent or dangerous surgeons, or to make decisions that are not consistent with their long-term goals.

What else scares me?  The political climate.  In the UK, the anti-trans rhetoric is positively toxic.  And the NHS (national health service) is a shambles when it comes to trans people.  It took me six months to get a referral to the transgender clinic and now that I have been referred I have a four-year wait for my first appointment…in other words, in the UK, I would have to wait four more years to just get a diagnosis.  Four more years until I could legally take hormones.  This is why so many trans people in the UK self-medicate.  

And while I might say this is dangerous, and in a way it is, you would not believe how little most people who prescribe these hormones to us actually know.  Any self-respecting trans person has to know as much or more than most doctors to ensure they are cared for in a safe and sensible way.  Crazy.

I am hoping to paint a picture of serious dysfunction in access to life-saving care.  And that is what it is.  Gender dysphoria is classified as a mental health condition in the Standard Manual.  But I think it is more complex than that.  It is not just mind.  It is body.  What do I mean?  My cells have feelings.  My cells have a mind.  When they first encountered oestrogen, they were so happy to finally get what they always needed, what they always wanted, I had pleasure chemicals flowing through my body in ways never felt before.  

I can’t say this is what it feels like to be female.  But I can say that it is what it feels like to be trans female.  And this feeling hasn’t gone away.  Some people who go onto oestrogen don’t get this feeling, and stop, and that is good, because it probably means that they might not have gender dysphoria.  And why do to your body what we do to our bodies to become who we feel we really are, need to be?  

Because if we didn’t, we wouldn’t make it.

So the fear of having this path diverted or taken away from me is so profoundly unsettling, it is hard to describe.  Other than, not knowing if I would be able to wait.  And clearly I have waited so long, so why does it matter now?  Because I took the first step.  I took the second step.  And now, my body has changed irreversibly, and continues to do so, and I live 100% as a trans-woman, and it is fxxking difficult sometimes.

At first I loved explaining it.  Talking all about it.  Endured the stares.  But now I don’t feel like talking about it so much.  I just want to get on with my life.  My life on the other side of the rainbow, the other side of my own vagina.

I have benefited from the “informed consent” approach in the US, which has given me access to medications, therapists, and so on and allowed this journey to begin.  But it also means that I find myself hopping on a plane every three months to see doctors, renew prescriptions.  I know we can do things remotely, but prescriptions don’t usually cross borders so well, and I like to take the care and time with doctors to make sure that I really understand what is happening to my body, and that we are making good decisions.

What else is going on.  A Republican might win the next election.  The official party line seems to be erasure of trans people.  From a surgery standpoint, insurance standpoint, that would be catastrophic.  I can imagine the first casualty will be exempting gender dysphoria as a pre-existing insurable condition.  For me, that means, why wait?

But it also means that the window might be closing for a lot of things.  Might be closing for me to change my birth certificate, my passport, my drivers license.  All things I want done before I walk out of the hospital.  I want to go in to that operating theatre as a legal woman and come out a physical woman—at least as far as they can make it through surgery.

I am also concerned about how these political winds will harm innovation, investment, and the discovery of new methods and techniques.  These advances in transgender surgery have only come about because there was money for doctors to make.  That wait lists are so long, and access so hopeless, you have to think that the demand continues to far outstrip supply.  It does.

I have read about the use of stem cells from the patient to grow vagina tissue.  They make a stent from a material which dissolves and take epithelial cells and grow them into vaginal tissue.  This “neo-vagina” is virtually indistinguishable from a natal vagina.  Thus far, this operation has been done only a handful of times on natal women who were born without vaginas.  

In all of these cases, and with the various methods of trans vaginas, there is a difference in lubrication.  A natal woman’s vagina lubricates when she is aroused.  A grown or grafted or flapped vagina does not…it may have lubrication, but this is a static state, rather than one which is based on response.  Over time, I am sure science will figure this one out.  But only if there is a market.

I don’t wish to rant, but I can’t help it…and it is an aside that is born from all that is above.  Sop many trans women and trans men are obsessed with this concept of “passing”.  Yes, do I wish I looked exactly like any number of incredibly gorgeous women in every way.  Yes.  Do I wish that I had female plumbing that would allow me to become pregnant?  Yes.  Do I wish I just been born female?  Yes.

But I can’t have these things.  And passing feels like a form of eternal condemnation.  Women were policed, and still are, by having their virtue thrown in their faces (‘she’s a slut’ and ‘she was asking for it’…you know the score).  And so many women were the most vigilante in this regard, the first to say something.  It feels very similar to what the trans world experiences in relation to this obsession with passing.

I want my own culture.  I don’t want to erase my past.  I don’t want to diminish the most beautiful thing I have ever been part of, being a father to such wonderful children, just being a father.  And yes, it hurt to be a man (that sounds ridiculous, and for any non-trans man, it would be), but as a trans person, every time I was reminded that I was male and not female was a kind of deep psychic wound.  And most people probably never think that way.  At all.  Why would you?  Most people probably never consider their gender.  I think a trans person never thinks about much else.  That has certainly been my life.

SRS, as the big milestone for me, can’t come soon enough.

But I wish for trans people to forge their own unique identity.  And I have found to have just as much in common with trans men as trans women when it comes to being trans.  Our perspective on life, society, sex and sexuality, and even spirituality, is totally unique.  Somehow the obsession with passing seems a terrible disservice to my fellow trans brothers and sisters.  And I understand that in this society, in this world, the way it is, as it is, that being trans is an enormous liability.  I see that.  And I don’t like having to depend on someone else to be my benefactor.  But in a way, that seems to be the path I have chosen.

I’ve never been good at that.  Receiving.  But now I need it.  I need help from so many quarters.  And I also find that because of this dynamic, I have no choice but to be a reluctant warrior.  I cannot disappear because I cannot.  It’s like having your back to the wall.  This may be why I can’t submit my way to safety.  Instead, I must fight.

Why all the drama? I have no job. My divorce has become so costly that my financial future has gone from reasonable to grim. There is little solace in thinking that she has also ruined her own financial future. The timing of surgery in this context becomes ever more important–while I still can. To look for a job before surgery seems disingenuous (I will need 3 months off from work after). So, I am in this kind of chute where I don’t dare look to either side for fear that I will lose control.

It sounds like the kind of mess that most trans-gals find themselves in. And because I had two jobs pulled from me on disclosing that I am trans, I have no illusions as to how hard this will be. And if I really had to, I could still pull off boy mode, but this will be impossible soon enough, and certainly once my legal sex has changed.

In other words, no time to slow down.