Notes on Gender Role Transition

By Anne Vitale Ph.D.

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FTM 101 -- The Invisible Transsexuals

by: Shadow Morton, Yosenio Lewis, Aaron Hans--James Green, Editor

Ed Note: For more up to date information regarding FTM International's current acitvites please go to the Female-to-Male International website. Click here. (November 29, 2011)

Revised September, 1997, Contact information updated Nov. 29, 2011

This paper provides an overview of FTM experience, focusing particularly on health issues, and includes basic information on:

 

The first image that most people associate with the term transsexual is that of Male-to-Female transsexuals (MTF), or shemales--people who started life with male bodies and who "want to be women." In the past seven years, due to increasing media attention and more transsexual men (FTMs) coming forward, the world has had to not only re-define what transsexual means to them, but also to re-adjust the image that accompanies the term.

Female-to-Male (FTM) transsexuals have been invisible for many reasons. Among them are class issues, pressures from the gay/lesbian communities as well as mainstream society, gender stereotypes, the ease of assimilation. It is impossible to present a thumbnail sketch that defines the FTM experience. There are too many ways to walk that path to give a simple explanation. Medical professionals have often commented on the stark difference between the MTF hierarchy and the blur that exists within the FTM community. Many MTFs define themselves in the separation of preop and post-op and the distinction between cross-dresser and transsexual, subscribing to the premise that one is "real" and the other a mere pretense or dalliance. These clear strata do not exist for the FTM. Many of us "blur," or exist within two or more so called categories. The old concept of going through the phalloplasty surgeries and becoming a "finished" man is losing currency within the FTM community as transgendered and transsexual men around the world are re-defining for themselves what it "means" to be a man.

There is no specific age when a person decides they are transgendered. The FTM community support groups serve those as young as fifteen years of age and those in their seventies. Many health concerns depend on when a person begins transition. Usually the younger folks adjust to the hormones with fewer side effects&emdash; sometimes migraines. This seems to be true from ages 15 - 40. Those beginning hormones in their forties to seventies need closer monitoring for high blood pressure and heart disease. Heart disease is more likely to occur with smoking, drinking, and unhealthy diet. Many FTMs who choose hormone therapy in their sixties and seventies have usually started with low doses and more infrequent injections while having liver and cardiovascular systems monitored more frequently through lipid screen panels. There has been very little long term study of testosterone use in FTMs, but logic dictates that many effects are cumulative. Young people should not neglect liver and cardiovascular health monitoring.

With these things in mind, we hope to present a clearer picture of some of the different needs of the FTM community, as well as comment on the general needs of the larger transgender community.

A. Hormones

Any person on hormones is a chemistry experiment. It is very important to listen to the FTM (or MTF) as they tell you what is occurring for them physically and emotionally. FTMs have learned to watch and monitor the changes they experience over time. On this note, it is very important that if you have a pre-op transsexual come to you for help, you educate that person to listen to their body and know how to monitor changes. It will be up to them to guide you through their changes so that you can help them navigate their future health as safely as possible. This is also true for the individuals who choose not to do hormones or surgery. Transsexuals are often dissociated from their bodies due to the schisms they experience between the way they feel and the way their bodies are (sometimes) perceived by others, or the way they know their bodies are. Many transsexuals have extremely high thresholds for pain, or cannot differentiate pain from other experiences.

It is important for every FTM to get a complete blood work-up before even beginning hormone therapy. Those who decide to go through the black market to obtain hormones are at risk for a variety of health problems. Even if someone comes to you who is not receiving injections through a program or doctor following the Harry Benjamin Standards of Care, it is important to listen closely to what they tell you. They will often times be able to tell you what it is that they need from you. (We do not wish to imply that we are telling you to throw out your knowledge or ideas. We simply ask that you not throw out the information and knowledge being given to you by the FTM in your office.)

Once hormone therapy has begun, it is a good idea to do blood work-ups every three months for the first year. If there are no indicators of complications, this can be changed to every six months in the second year. After the third year, unless complications arise, once a year is not unusual practice for blood work-ups. The blood work-ups should not only monitor bilirubin levels for the liver, but should also monitor the cholesterol level. An occasional check of the serum testosterone level is a good idea, to be certain that the level is within the normal range for a male of the patient's age.

In the United States, the most common approach to hormone therapy for the FTM is intramuscular injection. This is usually prescribed at 200 ml/cc, lcc every two weeks. This can vary between individuals, and it will take time to determine the proper dosage and frequency of injections. Testosterone Cypionate, a cottonseed oil suspension, and Testosterone Enanthate, a sesame seed oil suspension, are the two most common forms prescribed. There are doctors who insist on administering the shots. However, most doctors will do so only for the first few injections, and will then teach the FTM how to inject himself so the FTM can take care of this at home. Most doctors who insist on injecting the hormones themselves are also charging higher rates for the injections as well as the office visits. This usually occurs in rural areas or isolated areas where the FTM has little choice but to comply. Oral Testosterone is still sometimes prescribed, but is strongly discouraged. The high doses of testosterone administered through this method are harmful to the liver. This method has also caused high blood pressure in many FTMs.

A growing number of FTMs who have been on hormones for 4 to 5 years who have not had hysterectomies, have developed intrauterine complications. These range from endometriosis to fibroid cysts, to fibrous scar tissue forming around the reproductive organs, to absorption of the organs into the abdominal muscles or even, in a couple of cases, into the intestines. The rising number of FTMs who have been experiencing these complications has pushed many of us to ask for an hysterectomy earlier in our transition. Many FTMs, however, do not experience these problems, and for them hysterectomy may be an unnecessary surgery. Some FTMs require hysterectomy/oophorectomy for psychological reasons.

Some FTMs may experience migraines in the first few months of hormone therapy. This can sometimes be alleviated by adjusting the dosage or the frequency of injections. Whether the dosage should be raised or lowered varies from person to person. This is a totally experimental stage, and also a very important time for the doctor to be listening to the instincts of the patient. Many FTMs choose to weather the headaches. They usually dissipate after 3 - 6 months. Others may experience cold-like symptoms in the first few months; others may be at a higher risk for yeast infections for the first few months.

Diet is very important. Lowering fat intake will reduce the risks of high blood pressure and heart disease. Taking supplements of milk thistle can assist the liver in processing any toxicity. Smoking and drinking should be discouraged. If the FTM intends to pursue any kind of surgery, he should be educated on the damage smoking does to the vascular system. Most surgeons performing any of the alterations sought by transsexuals insist that the patient quit smoking 6 to 9 months before surgery.

Hormone therapy begins at different times in life for different people. Those who start at a very early age will probably notice a variety of changes at several stages of their lives. Even people who do not walk this path experience hormonal fluctuations throughout their lives. Those who begin hormone therapy later on in life will probably have fewer fluctuations, but will need to pay closer attention to the changes that do occur. Anybody is at risk of arthritis and heart disease, but with the added factor of hormone therapy, the usual course of events may not apply. It is also important to note that all of this information will vary from person-to-person depending on age, ethnicity, diet, and current health.

Listed below are some of the differences between the cypionate and enanthate suspensions.

Testosterone cypionate&emdash;This form brings on the secondary male characteristics sooner than enanthate. However, since this is a cottonseed oil suspension, more guys have a variety of allergy reactions to it. These reactions can manifest in the form of mild rashes or itching at the site of injection. Acne is usually more prevalent and harder to control. Muscle and bone density increase is fairly rapid. However, ligaments and tendons are at risk of damage or injury because they take longer to "beef up" in correspondence with the muscle/bone increase. Any sport activity for the first two years of hormone therapy should be approached with this in mind. The voice usually begins to change at two months and settles at about nine months. Body hair appears within the first two months and can continue to grow in new places up to seven years. Balding is a very real possibility. It can begin as soon as three months into hormone therapy. Fat distribution shifts: thighs and hips may flatten out. However, fat frequently does not disappear, it merely shifts to the sides and the gut. Depending on the FTM's body type and diet, the person will gain or lose weight.

Testosterone enanthate&emdash;Since this is a sesame seed oil suspension, it is usually easier for the body to absorb. The secondary male sex characteristics usually take longer to manifest than with the cypionate - usually the process is 3 - 6 months behind, though this can vary, too. This slower body adjustment can make it easier on the tendons and ligaments, however, the risk for injury still exists. Acne is less of a problem, and for some has been non-existent.

B. SURGERY

This is one of the more controversial aspects of the transgender (TG) experience. There are many TG folk who choose not to have any surgery, some who pick and choose which surgeries they want, and some who feel they have no choice but to go through all of them. There are also the moral pressures to consider from internal and external sources. Average cost ranges are as follows:

 

Chest.......................$2100 - $7500

Hysterectomy.............$10,500 - $18,000

Metoidioplasty............$8,000v- $15,000

Phalloplasty...............$15,000 - 150,000

Please keep in mind that these costs vary from doctor-to-doctor as well as from country-to country.

Most of the surgeries listed above can only be acquired by paying the surgeon cash up front. The cost is one of the weightiest factors as to whether a person decides to have the surgery or not. Many FTMs are under-employed, if not unemployed. Those who do seek surgical alteration often work 2 and 3 jobs to save the money needed. Some of the younger FTMs work the streets just for survival money, although a few have used this as a means to supplement other earnings for surgeries. A few FTMs have been able to acquire some or all of their surgeries through insurance. This is very rare since most insurance companies explicitly exclude transsexual treatments from their covered procedures.

When to have any of the surgeries is also an issue for many FTMs. The Harry Benjamin Standards of Care (SOC) clearly delineates when a transsexual can do certain things pertinent to their transition. Many transsexuals who only choose to do one or two of the surgeries circumvent the SOC. However, this can mean seeking doctors through the black market. The other concern for many FTMs is the condition of the body before and after taking hormones. There have been several FTMs who have sought and received different surgeries before taking hormones. Reasons for this will be disclosed in the following paragraphs.

The double mastectomy and/or mastopexy is the procedure most commonly sought by FTMs. The biggest reasons for this are image/presentation and comfort. Transsexuals are asked to dress and live in the world as a person of the gender they are trying to achieve for a set amount of time&emdash;usually six months to one year before they are allowed to pursue hormone therapy or any of the surgeries. The biggest obstacle for an FTM is usually hiding the breasts. However, this is absolutely necessary. Far too many FTMs have been humiliated, harassed, and even beaten up for walking into the men's room because their chests gave them away. This harassment is not exclusive to the bathroom situation. Mainstream society is notorious for its violence toward anyone presenting a conflicting image, period. Many FTMs choose to have this surgery before they pursue hormones for several reasons. With testosterone comes body hair. The chest hair that grows in around the sutures and incisions can, at the very least, be incredibly annoying, and in the extreme can become ingrown and even cause infection. Many FTMs also look to the advantage of estrogen keeping the skin more pliant as a bonus. Several individuals have gone through the mastopexy, waited 6 to 9 months to heal, and then begun testosterone therapy. It seems that most of these individuals have less visible scarring or less extensive scarring. The muscle growth into the chest with the testosterone seems to them more natural as well.

A couple of advantages to testosterone are that the healing rate (from surgery) appears to be quicker, and with the advanced muscle development, there is less chance of severed or damaged muscle.

Some of the older FTMs have had the advantage of having an hysterectomy before they've sought hormone therapy. Many FTMs feel there is an advantage to this as there will be less of a strain on the liver once testosterone therapy is initiated. Some symptoms of chemical/hormonal imbalance (such as migraines) often disappear after the FTM has his hysterectomy. One advantage of hysterectomy is the possibility of either reducing the dosage of testosterone or extending the time period between injections, thus possibly reducing the strain on the liver. Those who do undergo this surgery are sometimes advised to then take small doses of estrogen. Many refuse because of the implications of femaleness. Many people do not understand that estrogen is present in the male body as well. Testosterone is also used to alleviate osteoporosis, though, and estrogen may not be necessary. People should also be aware that excess testosterone in the system is naturally converted into estrogen.

There are many who choose not to undergo an hysterectomy and suffer no ill-effects, although there does seem to be a greater degree of difficulty dealing with the last few days before the next injection, known as the trough. In the 3 to 4 days before the next injection, many FTMs (with female reproductive organs still functioning) report irritability, shortness of attention span, headaches, fatigue, lack of sex drive, and sometimes cramping similar to menstrual cramping. Some FTMs who experience extremes of these symptoms then pursue hysterectomy, or opt for an oophorectomy.

In recent years, more and more FTMs are choosing the metaoidioplasty (also inaccurately referred to as genitoplasty, and often contracted to metoidioplasty). One reason is money. It is less expensive, and therefore easier to set one's sights on as an attainable goal. Metaoidioplasty is the freeing of the enlarged clitoris (micro penis) and construction of a scrotal sack with testicular implants. The patient can opt for several choices. A urethral extension can be constructed so that the FTM can pee from his freed penis. This choice carries the risk of infections, fistulas, and corrective surgeries for complications. A hysterectomy and / or vaginectomy can be performed simultaneously. If the vaginal canal is left intact, this gives the FTM better options if he chooses to pursue a phalloplasty in the future.

The phalloplasty is usually a series of surgeries, not just one. The surgeries are still brutal and leave extensive scars on several places of the body&emdash;usually the inside of one forearm, the lower side of the torso, and the side of one thigh. Although these surgeries have been improved upon in the past ten years, there are still major drawbacks that deter many FTMs. The amount of time spent in recovery from the surgeries is extensive. Some FTMs have spent nearly one year in recovery stages from the surgeries, dealing with infections, getting corrective surgeries, and sometimes having to deal with their body's out-and-out rejection of the graft. The emotional toll of this surgery can be incredibly high. The surgically constructed penis is also non-functional sexually. It does not get erect or flaccid on its own. Most constructions utilize Teflon inserts to achieve erections. A few surgeons use pumps similar to those used for penile reconstruction in genetic males suffering from cancer or erectile dysfunction. There is a chance of rejection with this option. The constructed penis frequently does not look like a penis. In recent years, some doctors have been fine-tuning their surgical techniques and have also teamed up with tattoo artists for better aesthetic results.

C. GENERAL HEALTH CARE

There are many reasons why FTMs will be reluctant to seek out medical attention or even preventative health care. Many older FTMs have assimilated even without hormones or surgery. Their greatest fear is discovery. Sometimes even their own partners and families don't have a clue about their situation, and if they do, they are just as frightened of discovery. Mainstream society has not been very kind to anyone who is perceived as different. An even greater deterrent for many FTMs is the very treatment they receive once in a doctor's office or in hospital. Far too many of us have stories of being treated like the latest circus attraction, or of being outed to the entire waiting room. Perhaps the greatest fear for many of us is being involved in an accident and being "discovered" on the scene or in the emergency room. The person fears being unconscious or so severely injured that he cannot defend himself while outrageous remarks are tossed about, jokes are cracked, epithets are shouted, treatment is interrupted or stopped. All of these things have happened and continue to happen to transsexuals every day. If it hasn't already happened to us, it has happened to a friend, and we know that it could happen to us.

Since most insurance companies have explicitly written us out of their policies, most of us find it difficult to seek health care through those avenues, even if they are available to us. There have been many transsexuals who have been denied even simple health care because doctors and insurers can claim that the condition would not exist if we were not pursuing transition. Unless we can find sympathetic health care workers, we are often at the mercy of the big money machine insurance companies.

For the FTM specifically, dealing with the female reproductive organs can be a nightmare. Most of us do not have regular pap smears. The procedure is invasive. And again, finding a gynecologist who is sympathetic is difficult. Most FTMs will not seek out a gynecologist unless they are already experiencing symptoms of a problem. Most gynecologists, when it comes to female reproductive organs, have one goal--that of the continuation of the human race. When a male person with female reproductive organs comes into the office, most gynecologists see the organs and their possibilities, not the person. There are FTMs who have been dealing with severe symptoms of endometriosis or other health problems, and their gynecologists will not remove the organs at the patients request because the gynecologist sees the possibility of saving the organs. The FTM could be in severe, constant pain, not want the organs in the first place, have no intention of ever having children, even be past childbearing years, and the physician will override the patient's wishes just to save the reproductive organs. Never mind the physical, mental, and psychological strain this puts on the patient. Never mind that it is the patient's body.

Although many FTMs perform their own breast exams, most do not. They will rarely go to a physician if they find anything unless they already have a doctor who is aware of their situation. If surgery is recommended, many will not follow through because of probable exposure in the operating room. This is often true of hysterectomies as well. FTMs who choose to have one of the lower surgeries can get the hysterectomy at that time. If the FTM has opted to not undergo alteration surgery, chances are he is not getting any kind of medical attention for any health concerns.

Diet is an on-going concern. Many of the FTMs who are seeking some or all of the surgeries are working several jobs just to earn the needed money. There is little time for proper eating and sleeping. Those on the streets have an even greater difficulty meeting even the minimum dietary needs. Usually their main focus is on taking the steps they deem necessary for their transition. It is very important to point out to them that their health is one of the steps of their transition. If they do not have their basic health, they will not be able to maintain the work schedule they've set for themselves, they will not heal well from surgery or may even compromise their health to the point that they won't be able to have surgery, and that they may achieve the goals they've set for themselves and then not have the health to enjoy their new life to the fullest.

D. MENTAL HEALTH

Mental health is tightly intertwined with general health. Most FTMs tend to isolate. Not only do they deny themselves contact with society at large, they tend to isolate from each other. Even though this has slowly been changing in urban areas within the past five years, it tends to be the rule of thumb. Many FTMs who meet at meetings are happy to share the physical changes they experience. They are very private about emotional and psychological changes. The struggle against gender stereotypes is more pronounced for FTMs; or the majority of FTMs are simply more aware of gender stereotypes. This often creates a barrier between FTMs and MTFs, creating an even greater sense of isolation&emdash;an isolation from those who might be best equipped to understand or help us.

It is quite often difficult for any transsexual to feel confident about themselves or even feel good about who they are when so many people in their lives (and society as a whole) have regarded them as deceivers, evil, worthless, liars, mentally ill, psychologically unfit, ad nauseum. We are required to seek psychological treatment just for verification of our circumstances. We are told how we are to act, whom we are allowed to love what our sexuality may or may not be, what clothes to wear. Many of us have been taught to lie about who we truly are by the very people who are supposed to be helping us learn to accept who we are. It has only been within the last ten years that some therapists and psychologists have become guides to our process and let us come up with the answers to who we are. Needless to say, the trust level transsexuals have for therapy and mental health professionals is very low. Most sympathetic counselors understand that they will have to do a great deal of coaxing and laying down of a foundation for trust with most transgender folk just to draw them out.

The constant threat of being "outed," harassed, beaten/ and most profoundly, the threat of being killed is an everyday concern that wears on transgender people. People in the mainstream feel that Brandon Teena "got what he deserved, because he deceived" the people in the town where he was murdered. Sean O'Neil received the same general response from his neighbors: people felt he deserved to face the charges brought against him for deceiving those around him. Some of those charges were valid. However, the majority of them were not. (Ask us for more information about these people's cases, if you are interested.)

If the person is "out" about their transition, or has even transitioned on the job or in a small town, the risks are even greater. The emotional and psychological toll of these threats is tremendous. There is the added threat in many areas of being locked up and committed to any number of treatments, including shock treatment. These kind of mental pressures make every transgender person susceptible to mental illness of one form or another at any given point in their lives. This does not mean that we are mentally ill or incapable all of our lives. Because this is usually the perception that we encounter, our frustration level is only compounded. The suicide rate for transgender folk is very high. Substance abuse, eating and sleeping disorders, abuse as children, and domestic violence have only recently been being viewed as symptoms of the social pressures that transgender people are under as opposed to being a part of our so-called illness. Not only do we need more help around these issues, we need more education and compassion.

As more and more transgendered people come together and share their experiences with each other as well as the rest of the world, the primary emotion that arises is anger. It is usually the first barrier that must be dealt with by mental health professionals. Because of that anger, transsexuals can be marked as socially unfit. Western medicine's approach to classifying the symptom and not dealing with the root problem(s) is constantly used as a weapon against transgender folk. Until transgendered people are given space to feel safe, that will continue to be true. It is not just the transgendered folk who need help or have a problem; it is society as a whole.

E. SEXUALITY/SEX/STDs

By and large, the transsexual condition is referred to, and often dealt with, as a sexual problem. Gender identity and sexuality are two separate aspects of our lives. Yet, it is amazing how many people have trouble conceptualizing the difference. Since transsexuals began approaching the medical community after W.W.II, the general view of those practitioners was one of taking a social deviant (socially embarrassing, "effeminate" men) and through chemical and surgical adjustments create a socially acceptable woman. Once it was discovered that a portion of these "new" women took female partners and identified as lesbians, the medical screening process was tightened up. Those who identified as anything other than heterosexual were forced to lie. If they mentioned any behavior that smacked of bisexuality or homosexuality, they were rejected from most gender programs. Those who felt they could not fight the system learned to lie. The medical community taught many transsexuals that their gender and sexual identity were inseparable.

One of the first people to challenge the gender programs and the medical professionals on this attitude was Louis Sullivan. He was the founder of the largest and longest-running FTM organization (to date) in the world, now known as FTM International, Inc. Lou identified not only as an FTM, but also as a gay man. He spent ten years of his life writing letters, personally visiting doctors, educating them, and persevering against the system. For ten years, he was denied hormone therapy or surgery. Finally, his persistence paid off and he was granted the right to pursue the treatment he felt he needed. He was the first FTM who openly led the way for others who identified as gay or bisexual.

Within the FTM experience, the entire gamut of the sexual spectrum is covered. A large portion of FTMs identify as heterosexual men who date and even marry women. There are those who identify as non-sexual and others who see themselves as asexual, choosing only self-stimulation. A large number of people identify as gay or queer, others identify as bisexual. There are those who identify as pansexual or simply sexual.

Of course with the exploration of sexuality comes the discovery and exploration of sex. And with sex, the specter of HIV/AIDS and STDs arises. Most of the FTMs on the street hustling for survival and money are fully aware of the risks they run. They face some of the tough problems that other male hustlers face on the streets. Most johns will pay higher dollar if they don't have to use a condom. In San Francisco, $10 to $30 dollars will get you a blowjob. These are usually performed with condoms. To kick without a condom, the asking price is $75 to $150. Several of the young men have commanded prices of $500 or more for the john's privilege to not use a rubber. It seems an awfully low price for their life. The chance of drug use, mostly intravenous, is high for these young men. To our knowledge, at this point in time, the number of young FTM men who work the streets is low.

The FTMs who are probably at the highest risk of transmitting or contracting STDs are those who identify as heterosexual. Many hetero FTMs feel they are immune to HIV/AIDS because it is still considered a gay disease, and not all FTMs emerge from the dyke community. Their biggest risk is their ignorance and lack of education. This is probably less so in urban areas, but the attitude is still alarmingly proliferant. Not surprisingly, those FTMs who identify as gay or bisexual are usually the most educated in regard to any STD as well as safer sex practices. This has not, however, kept FTMs from contracting HIV or other STDs. In both urban and rural areas, the number of FTMs who have sero-converted has risen in the past three years. Herpes is wide-spread if not epidemic. A large number of FTMs have spoken up about cases of gonorrhea as well. When asked why they choose not use condoms or other forms of protection, many state that they have felt pressured into not using them. Several have spoken of being told they won't be seen as "real" men if they insist on protection. This kind of pressure has come from straight women, bisexual men and women, and gay men. Peer pressure seems to run the gamut in the sexual spectrum as well. More education is needed about safe sex that recognizes the unique conditions of FTM bodies and psyches.

For further information on San Francisco area, national, and international resources for FTM transgendered and transsexual people, contact:

FTM International, Inc.

601 Van Ness Ave. Suite E327, San Francisco, CA 94102

877) 267-1440 info@ftmi.org (email)