There are aspects of being a woman that are really lousy: I brought my son’s Mazda in recently for service. I stepped delicately out of my car in skirt and heels. A gentleman held the door for me as I walked up. This visit was routine, just an oil change, filter—or so I thought. The service was to have been short so I waited for the work to be completed. I thought I’d be then on my way. After an hour or so, the service manager, Ahmed, called me to the desk and explained that there was an additional problem that had been discovered. They recommended replacement of several of the hoses and belts. My simple oil change had suddenly leapt from $64 to nearly $900. He tapped a pencil while speaking with me. When I asked for an explanation and consequences if I chose to wait on replacement, the tapping frequency increased, oddly enough, as though this additional explanation would add appreciably to the cost of the repair. Although I am a medical school graduate, I received no education at any level that prepared me for the challenges of dealing with an auto mechanic as a woman. If I pressed further, I understood that eventually the explanation would degenerate into some sort of technical words that, when translated, meant I would never understand. I recalled my prior visit to a more elite dealership whose service manager had insisted that my complaint about a malfunctioning door latch was best resolved if I would purchase a very expensive, new, German battery. His explanation made about as much sense as treating a gangrenous toe with cholecystectomy. But at least I would never get gallstones, I thought.
If they only knew…
During my later professional life, which has now narrowed to reconstructing genitalia, my experiences (both in medicine and at the service department) are shaped by my prior history as having lived as a male for 36 years (with overlap as an obstetrician/gynecologist). I don’t talk about my past—because in public I really do not need to do so—I live as woman. I see my self that way—as does most of the world. Amazing. But like any good Boston accent, you take a part of your past with you. It is an aspect of who you are and, if I could have, would not have avoided many of my masculine experiences. Despite the adolescent bullying, despite the longing and sadness, my struggle makes me who I am. I liked learning to throw a baseball as much as I enjoyed being casually ushered into Nordstrom’s lingerie department fitting room for the first time. And I am a very strong—yet feminine– woman as a result. Transgender, though not for the faint of heart, is a fascinating journey.
During my years as a surgeon performing Gender Affirming Surgery (GAS), numerous acronyms have been assigned to the process: SRS (Sex Reassignment Surgery), GRS (Genital or Gender Reassignment Surgery), and, most politically correct, GCS (Gender Confirmation Surgery) because, I suppose, none of the previous acronyms adequately express the factual aspects of what is being accomplished and, perhaps, because no one likes GAS. On a karmic level, it is the association of GAS with my many memories at auto dealerships that cause me to avoid this acronym.
Among the many interviews I have had with news media, the question most often posed to me, often with the suggestion of dread, “how often do patients regret their decision [to have surgery]?” The very question itself exposes the still held myths that many continue to hold regarding the transgender process. The question itself supposes there to be some sort of choice in the matter, as though choosing to change gender could potentially come with ghastly consequences. As though a buyer’s remorse situation might exist should someone fail to exercise a solely male (or female) persona throughout the course of one’s life. As though life was handed to all of us as a one-act play with no set or costume changes.
The fact is, an increasing number of individuals around the world are choosing to live in a non-binary gender role, to experiment with the many notions of gender roles in society and even to physically change their biological sex organs to match their internal concept of gender identity, so-called sex change surgery, my surgical subspecialty. But please do not panic—there will be a leveling off. Prevalence and incidence numbers are difficult to come by (for many reasons). Once rare (less than 1:10,000), many experts are insistent that the numbers of transgender persons in the US may approach nearly 1 in 2000, possibly higher. Regardless, Transgender is most certainly on the increase in terms of numbers and visibility, with ever more credible and accomplished persons stepping up and coming out as Trans*. Most fascinatingly—particularly among young trans kids—-is the nearly identical incidence of Female-to-Male (FTM) versus Male-to-female (MTF) individuals. I see this fact as further suggestion that transgender is a predominantly biological process (though with important nurturing input).
The evidence for Transgender as a biological rather than psychological entity—and having relatively little to do with sexual attraction— remains largely circumstantial. There is a region of the hypothalamus called the stria terminalis that appears to be different between the sexes and matches those of Trans* individuals’ respective gender identities (Nature, 1990)—but the data is autopsy data and that isn’t much fun for the study subjects. Transgender persons feel differently from shortly after birth in most cases. Well in excess of 90% of my surgical clientele felt some level of discomfort with their assigned gender prior to six years of age. And we all know examples of kids or adults who, for whatever God-given reasons are just not as feminine (or masculine) as you or I.
Because of the difficulty, disruptiveness, discrimination and, sometimes, shame associated with the process, many are calling transgender the last wave of the Civil Rights Movement (and me, the Jackie Robinson of Gender, btw). There remain enormous repercussions for transgender individuals who experience disproportionate victimization in hate crimes, violence and denials of opportunity and basic civil rights. It is for these reasons that we all need to have an appreciation for Trans* in whatever form it impacts our personal or professional lives. It is an enormous struggle for these individuals and yet another important hue in the diversity rainbow that makes the human experience so meaningful.
Transgender is an umbrella term that is meant to be inclusive of gender non-conformity, whether it is drag, cross-dressing, transsexual (physically seeking to change sex) or even gender neutrality (non-gender).
Gender identity is the notion of one’s sense of maleness or femaleness.
Gender expression is the socially acceptable difference in hair, makeup, dress and behavour that society prescribes to differentiate between a male gender identity and a feminine one.
Gender dysphoria is discomfort with one’s assigned birth gender and is the currently acceptable diagnosis for individuals seeking cross sex hormone therapy and/or transgender surgery.
Sexuality is to whom one’s attraction is directed.
So yes, despite my inadequacies at the service department, despite the general assumption, at times, that I know nothing about anything technical, despite the long lines for restroom stalls, the 3-ounce liquid limit in carryon luggage, the male UW medicine residents who stared at my breasts and did not hear what I had to say about a mutual patient, I love being a woman.
I love the trust that society offers me as a female. I love the sisterhood that other women hold for one another including the unknown woman at O’hare International Airport who offered to hold my pizza box while I used the toilet instead of squeezing into a stall. And the other who found my purse in the bustling public restroom at the New York New York Casino in Las Vegas and took it—unpilfered—to lost and found. The soft smile, the ‘sweetie’ approval. I love that kids run to me without fear. I love that men (and women) notice me when I look nice and make an effort and that I get an occasional ‘pretty girl discount’. I love the makeup, my eyes, my clothing and the softness of my skin. I love the way my eyes look in the morning, with just a smudge of last night’s mascara. I love worrying about what I will cook in the kitchen for my kids at night—and that 2 of them choose to live with me—even at age 18 and 23.
Then again, I know—-and am comforted—by the fact that most men would not trade places with me for the world. Life is good.