On Transgender Children and Medical Intervention

On Transgender Children and Medical Intervention

I saw this post fly by on my Twitter timeline earlier and I've been thinking about it for the last hour or so. I have deep sympathy for the quoted person, and this will not be a thread that invalidates their pain or experiences.

I have some thoughts I want to share.

The first thing that springs up is just this intense sadness and empathy for this person who has clearly been through a lot of trauma with regard to their to identity and trying to find their path. None of the decisions leading up to irreversible transition choices are easy ones. 

I do think there's a very real tendency for many well-intentioned people to encourage a path that they themselves have not walked, and could not imagine walking, because they believe that it will reduce the suffering of the person they're encouraging. 

But to cast transition as sunshine and rainbows, as a surefire release valve for intense dysphoria, as the person quoted describes, is a straight up lie, well-intentioned or not. 

I'm hopeful that the medical professionals who advised them were a little more professional and even-handed than the hyperbole discussed, but maybe not.

I want to both acknowledge their pain and unpack a few layers of the complexity here. 

In my experience, and from what I have observed in others, there are often very complex emotions in play with dysphoria that address your body, your social role, your ideal desire, and what is permitted and encouraged by those around you. 

Transition may not resolve your feelings or issues with any of these four spheres, no matter how far you take it, because you're only partially dealing with external influences. You're also grappling with self-perception. 

Culture has changed a lot in terms of permissiveness with gender roles and identity in the last 20 years, and this is, broadly speaking, a good thing. It creates less coercive pressure to feel bad about yourself as a human being if you defy conventional gender norms. 

But also it allows for (and even encourages) medical interventions that may not be necessary or useful to address the root problem with dysphoria, which is a wobbly tangle of feelings about who you are, your body, and how you fit into the world. 

These interventions may also be incredibly useful and in many cases life-saving, but you don't really know unless you've taken the time to unpack that wobbly ball of feelings and can leap confidently into irreversible changes. You cannot predict how these changes will make you feel. 

I have often wondered what my life would have been like if I had grown up today instead of 30 years ago and had the safety to discuss my feelings about myself and my gender with a trained professional in my teens. 

I most likely would have been someone who asked for puberty blockers, someone who wanted surgical intervention as early as I could get it... and I'm not sure it would have made my teen years much easier in retrospect. In many ways, they might have been harder. 

It's so hard to say. Puberty is challenging for most people, and figuring out who we are is hard enough without dysphoria in the mix. When you're a teenager you tend to lack a lot of self-awareness of your real motivations. You also lack the experience of the adult world. 

I tend to think that some of the well-intentioned rhetoric around transition can be actively harmful to people when they have an ideal in their head about what it's like to live as the opposite gender that doesn't match with reality on multiple levels. 

The first level is that it's very hard to actually understand what the internal experience of living as a different gender from the one you grew up with is like for people who grew up as that gender. You can't see many small nuances of expectation and experience. 

I can only guess at what AFAB people see when they look at men, especially as a teenager, but it can be very lonely and difficult to be a man in the world. There are numerous dynamics in play that I can't imagine a teenager appreciating. The same is true for being a woman. 

Many of these dynamics are things you can't even appreciate or understand until you're an adult. What does a female teen know about male adult work politics and status? About competing for a partner with other adult men? What does a teenage boy know about group expectations and social posturing among a group of adult women?

You can't possibly have a wholistic view of what you're signing up for, and the same is true for MtF teens. When you're deeply unhappy with who you are and how you present, your idea of the alternative is not gritty nuance. It's all too often a shiny ideal. 

The second level of the issue is the reality of what medical transition can offer you. Surgery is unlikely to ever live up to the ideal you imagine in your head, and regardless of happy talking points, it's not the same biologically (or experientially) as a cisgender body. 

It will leave scars. It will not be perfect. It may not even satisfy you in terms of appearance or function despite the best efforts of the surgeon. You may still have to deal with things you find unpleasant about your body, and then new additional ones on top of that. 

If you already have severe body image issues (and I've never met a TG person who doesn't), altering your body may lessen aspects of your dysphoria, but it's not a cure for a negative self-perception or lack of self-love. Hating your body doesn't go away when the scalpel pulls back, and depending on a roll of the genetic dice and your personal skill and dedication and observational ability, you may struggle to pass even deep into your transition and find new things about your body to hate. 

I don't mean to be overly negative about this, but I want to be real, because it's a really big deal, and it's a disservice to everyone to gloss over it like it'll just be okay. It might not "just be okay," even if you eventually find peace within yourself. That's the reality. 

I am happy with the choices I've made in my life. I don't think I could have ever found as much peace as I have if I had continued living as a man. But it's been anything but an easy road, full of plenty of pain, and there's a reason these decisions are made with gravity. 

When I went to have gender reassignment surgery, I had already been married. I had graduated from college. I had worked in the corporate world for a number of years. I had been through several years of therapy and thinking about these issues as an adult. 

I had already been on hormones for some time with the attendant risks of sterility, but even still that was the first time I was facing a truly irreversible decision I couldn't come back from.

I took a walk around a lake at a nearby park the day before I was scheduled. 

That was a heavy walk. I sat down by the lake and wrote a journal entry, staring at the water, and just deeply searched myself to see if I was really going to take this jump. I was giving up my marriage, the definite potential for children of my own, and I had no guarantees about the outcomes. 

A trans woman who was there at the center with me had come back to go under the knife again after her surgery had left her bleeding for months longer than it should have. Other people had warned me about the potential loss of orgasmic capability, possibly permanently. 

It was on the same trip that I heard FtM patients who were there for bottom surgery talk for the first time about what it was like, and the expected outcomes for even a "very successful" FtM bottom surgery. I do not envy those guys--there is a reason many TG men forego it. 

And even with all this preparation, all this knowledge, all of this pain I had endured and money I had spent (completely draining my savings because my health insurance didn't cover it back then), I stared at the lake...

...and I wasn't sure I was ready to do it. 

There's no way you can be sure you're ready when you're standing at the precipice of a one-way irreversible door that will change your life forever in ways you can't predict. No one should ever be rushed into this or encouraged without a proper appreciation of the gravity of that step. 

I intentionally chose to make that leap that day with as much consideration as I could manage, and I now know that nothing could have prepared me for it. You can only go so far, and then you have to know yourself enough to know if it's worth it to you to jump. 

When I was going in for surgery, at the last possible minute before they put me under, the doctor stepped in and asked me to rank three factors for the surgery he was about to perform: Depth, Aesthetics, and Function.

They hadn't prepared me for this. I don't know why not. 

I paused to consider for a beat, and picked my rankings: Function, Aesthetics, Depth. I was terrified of losing orgasmic capability, as any human would be.

I'm not telling this story to be sordid. I'm telling it so that you can appreciate how hard this was. 

Jesus Christ... talk about a life-altering set of choices. That's a lot to weigh for a casually asked question 3 minutes before you're going in for a life changing surgery with a non-zero chance to kill you. 

I'm trying, unsuccessfully, to imagine how hard all of this would have been when I was 17. Even the hormones, even puberty blockers. All of these things carry substantial, life-long risks.

And that question?

Pick 3, make a wish. Good luck. 

The next thing I knew I was groggily waking up with my mother sitting beside my hospital bed, and I couldn't really feel anything different about my body. Emotionally, I didn't feel any different at all after my surgery either. There was no magical glow, no POOF, you're a woman. That's not how it works. 

The thing that did make me feel different was when my mother handed me a mirror. I had decided on the last week to also have the surgeon do a tracheal shave while I was under, because it was cheaper than doing it later and I had a pronounced Adam's Apple. 

For the very first time I saw myself in a mirror from profile without this extremely male-pattern secondary characteristic, and I cried because of how much more feminine I looked after the procedure had been performed. It was minor by comparison, surgically. A small thing. 

I mention this specifically to highlight the importance of self-perception to dysphoria. GRS made my life easier as a woman in a myriad of ways, but the tracheal shave was probably 2-3x as psychologically impactful back then. 

And then... a lot of really unpleasant things happened that we don't normally talk about openly because they're unpleasant. A month of in-house hospital care, excessive bleeding, and barely being able to walk. 

Painful dilation, multiple times per day, every day, for a year. I'll let you google that if you don't know what that means. Lots and lots of pain and discomfort and awkwardness because you still have to leave work to go home and dilate. Sex often hurt even when I was healed. 

And despite my best efforts, and despite prioritizing function, despite doing everything I could possibly think of to help, it was roughly six years before I had another orgasm.

I spent that entire time not knowing whether I ever would. I made peace with it. 

Some people love to complain that trans people are primarily sexually-motivated or insist that it's a fetish (thankfully not as much anymore), but you go in knowing that losing your capacity to orgasm is possible and deal with it if it happens.

How would you feel if that just turned off for you? 

While much of this did lessen my dysphoria toward my body, none of this was what I wanted or had asked for. It was what was available to me. I'd done my research. I was smart and resourceful. It was an acceptable compromise, given other options.

I went in with eyes open. 

And even so I was so not prepared for the reality of it. You grit through it. You tell yourself that it's temporary. A lot of it is. Sometimes. Sometimes you live with your compromises because you can't have what you really want.

That's the key, though. 

You have to really know what you want and what you're giving up and what compromises you can bear, and you have to be enough of an adult to be ready to accept it as it comes, knowing that it may not be exactly what you had hoped and will be hard in ways you can't anticipate. 

I have so much empathy for trans kids, and also I can't imagine having to grapple with these decisions at 17, or 13, or younger. I could barely do it at 26. I'm honestly not sure if I would have preferred potentially guessing wrong to living with an extra decade of dysphoria. 

Even once you take the leap, all you've done is change your body. You still have to live with yourself every day, in the same body, slightly altered, and learn to love yourself along with a host of new challenges to distract you. Dating does not get easier when you're trans. 

Surgically altering yourself doesn't really make it much easier to see yourself as a man or a woman. It can help, sometimes, when you're looking in the mirror or looking at yourself through the eyes of others, but assuming a gender identity is something you have to grow into. Lived experience. 

When I first started talking to a therapist about all of this, sharing the feelings I'd concealed for so long from everyone, the very first thing she did was work with me to unpack my notions of masculinity and femininity.

She was very good at her job. 

The work that we did was focused on helping me to be happier with myself and trying to get down to the root of the ways in which my perceptions of femininity and masculinity might be clouding my judgment. Her emphasis was on the feelings--not medical intervention. 

We unpacked that for some time and worked on ways to lessen my sense of dysphoria, increase my self esteem, feel good about my social role, irrespective of gender. We peeled back the layers as far as I could take them while I was struggling. Small steps. Focused on comfort. 

I struggled with that for as long as I could, went through another year of suppressing things and experimenting with gender presentation, and eventually I realized that the steps I was taking toward a more femme presentation and role were the only way I wanted to live. 

But my god, the cost. All of the costs. I wouldn't wish it on anyone. I certainly wouldn't push someone toward it.

The only way I was willing to take the leap at all was that I had confidence that I needed to do it, irrespective of outcome, and I was ready to accept that. 

It still took years of effort and work to grow more comfortable with myself, to learn to like myself, to eventually come to love the person I was and get comfortable even in my preferred gender presentation. It's been a long road, and I'm still on it. 

The surgeries felt like necessary steps along the way for me, as a personal decision, but they only played a small role in my ability to learn to love myself and accept myself as a woman--and also for others to do so. 

And you still never get this 100%. I spent a long time closeted and passing, and people still knew I was trans at times. Tons of people still don't think of me as a woman, even if they're polite about it, and I can't make them. You just have to live with that. 

When you're trans, there is no magic bullet. You can't have what you really want. What you can do is focus on fixing how you feel about yourself, and making the compromises you feel that you need to with as much self-knowledge as you can muster. 

If you misstep on the big choices, there are no take-backs. You live with that forever. You can still have love and peace, friendship and confidence, a partner and a family, and whatever life you want to make from that point forward.

But you can't change your past decisions. 

This is a very, very big deal--especially for teenagers who have their entire life to have to live with these choices and necessarily imperfect knowledge of what they're signing up for. It requires strength you may not know if you have. You may not need to take the steps. 

And I'm sure this is very, very frustrating to hear when you're 16 and you want this more than literally anything else in the world. Your expectations may just be out of whack with the reality of what's on offer, though. 

There are no easy choices here. Parents can also be too restrictive, out of their own fear and concern, and do additional damage to children in a vulnerable space. Hoping their kids will grow out of hating themselves and their gender is kind of a shitty move too, honestly. 

Proactive, supportive action to help their kids work through these feelings is paramount and necessary, and I mildly support drugs which delay puberty (with limited knowledge of the side effects) while you explore these questions and paint a realistic picture of outcomes. 

But I am extremely hesitant to be supportive of permanent medical interventions before adulthood (even at 18, really) without a TON of unpacking these questions and painting vivid pictures of the reality of the situation, rather than the ideal. 

This isn't a recommendation thread. This isn't a warning thread. This is an honest thread about the truth of transition, which is that it's incredibly difficult and painful in ways you can't anticipate even with tons of research. 

Some of those painful experiences are things you won't encounter until you've spent years living as the opposite gender, even if you pass. It was a different experience to realize I'll never have kids of my own at 34 than it was at 26, even. 

Even still, I wouldn't go back and make different choices if I could (except to be gentler to myself and others along the way). But you can't take it lightly. You can't see it as a magic solution. Whatever you're hoping for, it will probably not be as good as you imagine. 

It might be better than the alternative, but it's not going to be everything you wish it was. It can't be, because it's not the same, as much as people might reassure you that it is.

You have to understand the compromise you're making and decide if you're okay with it. 

I don't know that I would feel comfortable letting my own child make this decision for themselves. I'm sorry, trans teens. I know you think you know, but you don't. You can't. You haven't lived enough yet. There are things you're signing up for that you can't understand yet. 

This is not me invalidating your feelings or trying to be a gatekeeper. I know exactly how painful it is, and I know how hard it feels. This is me telling you, with as much empathy and love as possible, to put the irreversible steps off for as long as you possibly can. 

Your life is incredibly unlikely to become broadly easier as a result of irreversible medical transition steps, and you can go a long way toward building the life experience you need to make these calls without them. It's not fun, but choosing wrong is far less fun. 

And I'm sorry. Genuinely. From the bottom of my heart. It sucks that you're dealing with any of this. It's not fair. It's not your fault that you feel how you do. You don't deserve to have to be thinking about this at all, and I wish you didn't have to. 

I wish it didn't feel like there were no good options and that everything is hard. Sometimes you get unlucky and that's how life goes.

But whatever you decide to do, regrets or not, please believe me when I say you can still find peace and learn to love who you are. 

Do what you have to do and what you can do and keep your expectations realistic as much as possible. But know that you're beautiful and amazing even if you don't feel it in your heart, and that with time and effort you can come to feel this way too, even if you misstep. 

We're all human. You make your choices and you live with them. I'm happy with mine, hard as they've been, and even if you make choices you regret you're no less important and have no less to offer the world. You'll learn to live with those choices too. 

Love yourself, step forward with as much care, caution, and grace as possible, and strip your feelings as far down to the core as you can before you decide to alter the course of the rest of your life.

For some of us it's worth it. It may not be for you.