Category Archives: Trans

Issues that touch on gender identity and gender expression, transphobia, overall gender theory and binarism.

Why “Sex Change” Surgery is Medically Necessary

Popular opinion has it that Gender Reassignment Surgery (GRS, often popularly nicknamed “sex change surgery”) is a cosmetic issue and motivated by a simple “want” to be female or male, by someone who was not born as such. However, extensive medical research into transsexuality dating as far back as the 1920s and continuing through modern studies have demonstrated otherwise, and consequently, medical standards of care have included GRS as a necessary procedure for decades. In order to understand this, people will honestly need to put aside preconceptions for a moment — and also realize at the same time that most transsexuals would rather see a health system in which preventative and quality-of-life treatments were uniformly covered, rather than one in which someone’s eye surgery or tendon issues are not, thus creating fighting amongst people in simultaneous need.

The experience of being transsexual involves one’s entire identity. They attempt to hide who they are, living a lie that feels unnatural in order to live up to others’ expectations, the hiding driven by a spiralling sense of shame and self-loathing, until it becomes an experience many liken to “suffocating,” or vents itself in an explosion of frustration. Transsexuals are unable to explain why they feel that their gender should be something different than their birth sex, and sometimes spend years attempting to mask themselves, to “pass” as the gender that society expects them to be. This restricts their ability to function socially, emotionally, psychically, spiritually, economically (it’s hard to be productive while constantly feeling out of one’s element and/or “backwards”), maybe sexually, and leaves them often suicidal as a result. If this continues into later adulthood, often a crisis point is reached in which the person suffers a complete emotional collapse.

“Gender Dysphoria” is the name for this condition, and treatment follows the standards of care established by the World Professional Association of Transgender Health (WPATH, formerly HBIGDA), which includes GRS. No less than the American Medical Association has stepped forward advocating the necessity of surgery and its coverage. In fact, like the AMA, the American Psychiatric Association and their Canadian counterparts support GRS as a medically necessary part of treatment. It was partly for this reason that the Ontario Human Rights Commission ruled in 2008 that that Province should restore coverage of the procedure.

Treatment of Gender Dysphoria encorporates surgical and endocrine intervention, because analytical and aversion therapies have historically proven damaging. As much as mainstream society would like to believe that electroshock therapy, anti-psychotic drugs or conversion (“ex-gay”) therapy would help transsexuals “just get over it,” modern medicine has realized that this approach simply does not work, and usually results in suppression, suicide or extreme anti-social behaviour. Aligning body to mind, however, has enabled transsexuals to become valued and successful people in society. There are, in fact, a few transsexuals who feel that they can live without having GRS, but they are the exception and not the rule.

Gender Dysphoria (sometimes called “Gender Identity Disorder,” or GID) is currently listed as a mental health issue, but ongoing study of both genetic ”brain sex” and Endocrine Disrupting Chemicals (EDCs) show the possibility of some biological causal factor. In a study released in October 2003, UCLA researchers identified 54 genes in male and female mouse brains that led to measurable differences by gender, and went on to indicate the possibility of a brain being gendered differently to one’s physical sex. Studies of EDCs show another, possibly concurrent potential that exposure to chemicals that simulate hormone characteristics — particularly between the third and eighth week of pregnancy — can affect the signals sent out to determine psychological gender and biological sex, which appear to develop at different times during gestation. In all fairness, nothing is conclusively proven at this point, and there is not a lot of research money being put into further study, as most pharmaceutical companies do not yet see a payoff from doing so. But the anecdotal and observational data from EDC and brain studies of human and animal populations would tend to support an innate origin or component of transsexuality, and coincides with transsexuals’ convictions that they “just knew” that they were female (in the case of male-to-female transsexuals) or male (in the case of female-to-males).

There is more. Current legislation asserts that most forms of identification and legal documentation can only be changed to reflect one’s new gender after surgery has been verified. Without GRS, many pre-operative transsexuals experience severe limitations on employment, travel beyond Canada’s border, and treatment in medical, legal and social settings in which verifying ID is necessary. Prior to GRS surgery, transsexuals also face limitations on where they can go (i.e. the spa or gym, or anywhere that involves changing clothes) and difficulties in establishing relationships — as well as being in that “iffy” area where human rights are assumed to be protected, but have not yet been specifically established as such in policies and legislation. In hospitals, prisons and such, they are housed by physical sex rather than their gender identity, creating potentially risky situations, unless the authorities directly involved choose to keep them in isolation instead. And at the end of the day, without GRS surgery, one’s gender is always subject to being challenged or stubbornly unacknowledged by those who don’t realize that a transsexual’s gender identity was not a matter of choice. There is also an extremely high risk of violence faced upon the accidental discovery that one’s genitalia does not match their presentation.  No other supposedly “cosmetic” issue so completely affects a persons rights, citizenship and safety.

Transsexuality is not widely known or understood in mainstream society, and should not be confused with other aspects of the larger transgender (an umbrella term) culture. Although much sensationalism can be made of something like medical coverage of Gender Reassignment Surgery, the realities paint a very different story.

Take care,
Mercedes Allen
Alberta Transgender Resources:

The Cisgender Everyone Else Standard of Care

Every so often, I receive an email through the albertatrans website feedback form that challenges me with something I hadn’t thought of before.  Recently, a query came in from a cisgender male who thought that I might be a good person to ask about finding a surgeon willing to do an “enhancement phalloplasty.”

Now, FTM phalloplasties I’m fairly familiar with, having dated a post-operative transmale and having had some pretty frank discussions with others.  Enhancement phalloplasties are something altogether different though, designed to lengthen and / or widen existing tissue, and weren’t really something I’d ever had occasion to look into or care about.  But ultimately, the conversation brought up some interesting and troubling thoughts about social preconceptions, the existing transsexual standards of medical care, surgical intervention and, well, human nature.
Continue reading The Cisgender Everyone Else Standard of Care

Almost A Person

(Part of GayCalgary and Edmonton Magazine‘s coverage of the delisting of GRS in Alberta)

It came in as registered mail.  This was good news of course, so when I’d received the notice, I ran down to the postal outlet to collect the envelope that would have news about my eligibility for surgery.  I knew what the letter should say because of a conversation with Alberta Health a couple days prior, so I was pretty excited.  I was to be one of the “46” (we still can’t figure out who is all included in that number) who was to be grandfathered through before funding for Gender Reassignment Surgery (GRS) would be completely cut off.  And then the girl behind the desk at the postal outlet said, “I need to see some ID.”

The bubble burst fairly quickly at that.  I pulled out my Driver’s License, trying to keep my thumb over the “M” specifying gender.  She pulled the card from my fingers, made a note and then stiffened for a full second when she saw the dreaded M.  Without moving her head, she glared up at me, crooking an eyebrow.  Then, after a pause, she tossed my license and the letter at me, saying nothing as she waited for me to leave.

Yay.  Outted again in a small town.

Continue reading Almost A Person

The Future of Transsexual Medical Care

This article has been a long time coming. Each time I’d revised it, some new discovery added a pertinent dimension that needed to be addressed. But one thing is certain: the future of medical care for transsexuals is changing — whether this change comes in the form of a delisting of Gender Identity Disorder as a mental health condition, or a revision of GID of any significance in the planned DSM-V, or simply new scientific discoveries akin to the finding surrounding the elongated Androgen Receptor gene or studies of Endocrine Disrupting Chemicals such as diethylstilbestrol (DES) that call for further research.

What is needed right now is to assess what our community itself can do in order to (best case scenario) drive the change toward a better model of transsexual health, or at least to (worst case scenario) avoid a future in which transition and surgery are further restricted or made unattainable to the people who need them. I’ve said that I don’t think that we should scrap the existing diagnosis of GID without another medical model in place. We — and our trans medical professionals, students and allies — strongly need to work toward this alternate medical model now. Finding problems is easy; finding solutions takes much more effort. And I’m not presuming that we can just do this without the checks and balances from professionals that would typically be accorded to any other medical study, but there are some fundamental ways we can help shape the model of care to come.

Because if we don’t, someone will do it for us.

Continue reading The Future of Transsexual Medical Care

Trans Needs Assessment

(Update 2013: I wouldn’t even consider doing a post like this now.  But at the time this was written, it was in response to a query about trans issues in Alberta, while few trans Albertans wanted to respond to surveys or be politically engaged in any way.  Prior to 2009, in fact, many people were strongly opposed to suggestions of organizing, for fear of losing funding for reassignment surgery (which happened in 2009 and was restored in 2012).  In 2008, I tried to compile this to the best of my ability, voicing concerns that were raised in support groups and on message board — anything I was aware of at the time.  It’s inadequate, under-representative and is in dire need of updating with survey-based information.  I leave it in place because it does provide an introduction to some mostly transsexual-specific needs for people who are just starting to learn about trans issues)

Continue reading Trans Needs Assessment


Dr. Marshall Forstein, Chair of the Work Group on Practices Guidelines on HIV Psychiatry for the American Psychiatric Association (not to be confused with the American Psychological Association), has written a reply to the drive to have Drs. Kenneth Zucker and Ray Blanchard removed from the Work Group developing the revisions for “Sexual and Gender Identity Disorders” for the planned DSM-V.  In it, he writes:

“I hope that what I have written makes us pause a bit before we do something to alienate even our supporters and friends in the American Psychiatric and the American Psychological Association who have been very pro-gay and pro-trans in their deliberations so far. There will always be a vocal minority that claim otherwise, but the process is vetted by many people committed to scientific integrity and evidence.”

I and others have been accused of scaremongering in the ongoing debate(s) surrounding this issue.  Dr. Forstein has some excellent points for us to examine.  Some of the other aspects and debates, though, I still stand behind.

Continue reading Scaremongering


(crossposted in several places, and people are welcome to forward this on freely to others in the transgender and GLBT communities, as I see this as being very serious — Mercedes)

A short time ago, I’d discussed the movement to have “Gender Identity Disorder” (GID, a.k.a. “Gender Dysphoria”) removed from the DSM-IV or reclassified, and how we needed to work to ensure that any such change was an improvement on the existing model, rather than a scrapping or savaging of it.

Lynn Conway reports that on May 1st, 2008, the American Psychiatric Association named its work group members appointed to revise the Manual for Diagnosis of Mental Disorders in preparation for the DSM-V.  Such a revision would include the entry for GID.

On the Task Force, named as Sexual and Gender Identity Disorders Chair, we find Dr. Kenneth Zucker, from Toronto’s infamous Centre for Addictions and Mental Health (CAMH, formerly the Clarke Institute).  Dr. Zucker is infamous for utilizing reparative (i.e. “ex-gay”) therapy to “cure” gender-variant children.  Named to his work group, we find Zucker’s mentor, Dr. Ray Blanchard, Head of Clinical Sexology Services at CAMH and creator of the theory of autogynephilia, categorized as a paraphilia and defined as “a man’s paraphilic tendency to be sexually aroused by the thought or image of himself as a woman.”

Continue reading uh-oh.

Destigmatization Versus Coverage and Access: The Medical Model of Transsexuality

In recent years, the GLB community has been more receptive to (and even energized in) assisting the transgender community, but regularly asks what its needs are. One that is often touted is the “complete depathologization of Trans identities” (quoting from a press release for an October 7, 2007 demonstration in Barcelona, Spain) by removing “Gender Identity Disorder” (GID) from medical classification. The reasoning generally flows in a logic chain stating that with homosexuality removed from the Diagnostic and Statistical Manual (DSM, the “bible” of the medical community) in 1974, gay and lesbian rights were able to follow as a consequence – and with similar removal, we should be able to do the same. Living in an area where GRS (genital reassignment surgery) is covered under provincial Health Care, however, provides a unique perspective on this issue. And with Presidential candidates proposing models for national health care in the U.S., it would obviously be easier to establish GRS coverage for transsexuals at the ground floor, rather than fight for it later. So it is important to note, from this “other side of the coin,” how delisting GID could do far more harm than good.

Continue reading Destigmatization Versus Coverage and Access: The Medical Model of Transsexuality


When I was about three or four years old – enough to be talking but not enough to be in kindergarten – my mother carried me through the lineup to the tellers at the bank. I had never seen a person of colour, and so I’d been awed to see a tall fellow with that “purple”-deep colour of skin. I turned to my mother and said, “oh, mom, I’d never let myself get that dirty.”

My embarassed mother kindly explained that some people are simply born with darker skin, and that ended my experience of personally-felt racial bigotry. A few years later, I learned from a close friend I’d made from Trinidad that skin colours sometimes come with cultural differences. It never occurred to me that any one skin colour or culture was any better than any other.

But I did also learn quickly that others didn’t necessarily share that same blissful innocence. As much as it clearly puzzled me when people expressed their contempt for my friend, it was certainly apparent to me that their contempt was very real. Even in Canada, where hatred was nowhere near as entrenched as it was further south, racism thrived.

I’ve also experienced it from the receiving side, twofold, one from the perspective of being Métis, in a culture where Natives are largely despised. In this situation, shame is taught implicitly, where it is intimated that a person should take refuge in their French last name, or resort to referring to their nationality as “mongrel” rather than identifying themselves as Métis. While I have since learned to be proud of my culture and now mourn not having been able to learn more of the traditions associated with it, it was still a painful experience hiding and pretending that nothing was amiss.

My other experience of bigotry came from being transgender. Even though it took me several decades to finally transition, the feelings were always there, and every crass joke that people made about men in dresses or every condemnation of “those perverts” served to drive me further into hiding, further into shame and further into the nightly suffocated struggle that almost culminated in suicide many times.

So if we learn so intimately how painful it is from the side of the victim, why is bigotry so easily foisted around in our own community?

Every so often, someone turns up the tune, “I’m Not a Fucking Drag Queen,” popularized by the movie, Better Than Chocolate. When I’d first heard it, the song was cute for about the first minute that it took before I started wondering exactly what was wrong about being a drag queen and why we should despise being associated with them. Certainly, there’s nothing wrong with defining oneself and pointing out when assumptions made about transsexuals based on the behaviours of others are fallacious, but I fail to see why it needs to be done at someone else’s expense. And yet, there is an enormous rift between many of the transgender communities where this self-defining takes on darker overtones: transsexuals trying to differentiate themselves from crossdressers and drag performers, crossdressers who feel that people who would undergo surgery to change their bodies are extremists and delusional, drag performers who embrace being gay and who feel that their compatriots should just wise up and do the same… there’s an ongoing factionalism that in many communities continues to drive wedges between us.

It does not stop there. At the grassroots level, our communities often ostracize people because they choose to be non-operative (because it isn’t consistent with the “one true way” medical model), or because they have spent some time in the sex trade, or because they play in the leather community (even when they display a healthy differentiation between fantasy and reality, and are clearly transgender in the latter). FTMs and MTFs sometimes feel that they have too many different needs to belong in the same support groups, and intersex people often balk at any association at all with anything transgender, some of whom have never experienced dysphoria and might have been lucky enough to be assigned the right gender at birth. It’s not unusual to see homophobia rear its ugly head when debates flare up between those who work with the local GLB folks (I mean the ones who seriously try to be supportive, not proven nemeses like the Human Rights Commission a.k.a. HRC) and those who call anyone who does so a “traitor.…” And then there’s the support meetings I’ve sat through where people complain about or tell unflattering jokes about “Pakis.” Or the “drunken Indians” comments said with no care that someone in the room is Métis.

If one had any doubts:

“… Susan has said all along that she’s not like other transgender people. She feels uncomfortable even looking at some, ‘like I’m seeing a bunch of men in dresses.’” – The St. Petersburg Times, about Susan

I’ll dispense with my take on Susan Stanton quickly. Although I object to her comments, I do see her as a creator of her own misery. Where she complains that “the transgender groups boo me,” and that her transition is a somewhat solitary one, this is a path that she carves for herself. When she had decided to become an activist, she failed to educate herself in the diversity of the community and the many needs it has, and in so doing she dropped the ball. By surrounding herself with people who are telling her that “Most Americans aren’t ready for us yet,” she’s succumbed to their rhetoric, rather than giving serious thought to the matter. A neophyte to transadvocacy, she has no idea how thoroughly and deeply the history of betrayal from her friends, the HRC, runs. But she will find out, when the next betrayal comes along and leaves her hanging in the wind. And when that happens, I see no need for hard feelings enduring from her novice mistakes, provided she becomes willing to see and admit where she was wrong. From my perspective, the personal maligning ends there.

As much as her comment angers me, though, I think it’s important that the subject has been brought up, because this is not just about Susan Stanton. This attitude persists far beyond this one incident.

“… like I’m seeing a bunch of men in dresses.”

This isn’t an altogether unusual complaint, in my experience. I’ve seen the aversion that people have to transwomen who’ve been harder-ravaged by testosterone, with heavy brows, deep voices, large statures, strong jawbones, recessive hairlines, wide shoulders…. “How can you be comfortable being seen in a store with her?” I’ve been asked. “I’d be terrified, and have to make myself as scarce as possible….”

Sorry folks, but not all of these things can be corrected with cosmetic surgery. And those things that can are often so costly that they become inaccessible to much of the community. We don’t all face the same challenges. For some of us, transition will be a lifelong process, and stealth is not a realistic objective. Should rights and protections then be only available to those who are “passable,” based on some unknown subjective scale? While conscientious and active advocates know better, I think our community would be surprised at some of the grassroots answers to that question. And this doesn’t even begin to touch on how often the “men in dresses” attitude is used as justification for shunning crossdressers, some of whom are transsexual at heart but held back by life circumstances (children, spouses, careers) and others of whom are dual-identified and need to alternately express both genders with the same intensity that we need to live one.

Please also understand that I don’t claim this bigotry to be endemic of the entire community, which can be an invaluable source of support and friendship. But it does exist in pockets, and where it does exist, it drives people away from the support they need, and likewise drives away those who would be happy (or at least willing) to provide it.

“’But I don’t blame the human rights groups from separating the transgender people from the protected groups. Most Americans aren’t ready for us yet,’ Susan says. Transgender people need to be able to prove they’re still viable workers — especially in the mainstream.”

Until there is protection in place to occasionally discourage employers from firing workers just for being trans, it will continue to be a complicated and sometimes monumental task to carve a successful career, and will continue to happen only so long as a person can remain “passably” stealth and not draw attention… or cause the right-wing fearmongers out there to panic and pick up their torches. And as long as successful transgender people are not free to draw attention, no one will take notice of their accomplishments and associate them with transgender individuals, and this “proving” that is being touted will never take place. Is the world ready for a transgender city manager? In the rest of society, the answer to that would depend solely on personal job qualifications – apparently, we’re to be patronized into believing that we’re not ready for that, yet. And the wonderful thing about the Barney Frank trumpet-that-there-isn’t-enough-support-of-transgender-rights approach is that the louder and more frequent they get on the subject, the more they will convince the legislators who might have once voted for transgender rights.

There is a reason that society associates transgender people with “shemale” porn, bank robberies, unemployment and marginal lifestyles. If you’re not lucky enough to be deemed suitably “passable,” it can be difficult to secure the lowest of jobs – whatever the qualifications. With the difficulties sometimes just in landing a minimum wage job at McDonald’s, coupled with the costs of hormones and surgeries needed just to arrive at a point of peace with oneself, frankly, the sex trade is unfortunately one of the most viable solutions. This will not change until a signal – one with some legal clout – is sent out into the professional world that it is no longer acceptable to exclude transgender people from more viable career paths.

And the transgender community will not be helping itself in pushing forward for these kinds of needs as long as it is still wrapped up in exclusion, distaste and division, and creating environments in which advocacy continues to eat its own. Often, I’ve heard people trumpet that Sylvia Rivera, Marsha P. Johnson and others who threw the first stones that touched off the Stonewall Riots and the gay liberation movement were transgender, in protest of the gay community’s past history of excluding us from the bargaining table. And far too often, I’ve heard (sometimes in the same breath!) derision of drag artists, sex trade workers and anyone else deemed to create a “negative impression” of the transgender community. But at the time of Stonewall, Sylvia Rivera, Marsha P. Johnson et al were drag queens and prostitutes. Sometimes, I think that the only thing that has changed since Stonewall is that gradually some of our community have managed to escape the ranks of the disenfranchised, and are trying to distance themselves from them. Once again, there is a repeat of the cycle of jettisoning the less fortunate – financially, physically or both – and some of us seem to have no qualms about doing to them what was done previously to us (and for exactly the same reasoning).

From time to time, it’s good to remember what inclusion really means, and embrace the consequences. As far as the move toward exclusion, I’ll have no part of it. I’d never let myself get that dirty.