Introduction
Being transgender doesn't necessarily mean a person wants to have a different body. Many transgender people are comfortable in their bodies; they just identify differently from how the doctor labelled them when they were born. However, many transgender people feel dysphoric about their bodies. Dysphoria is defined in the WPATH Standards of Care as "discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) (Fisk, 1974; Knudson, De Cuypere, & Bockting, 2010b)." So, a person can feel discomfort or distress surrounding their genitalia or secondary sex characteristics (like breasts, facial hair, or other things that develop during puberty) related to their sense of gender identity. Sometimes, this discomfort can be so extreme that it can keep people from forming happy relationships and cause depression and other mental health issues. It can make a person feel as if their body is just an inconvenient or painful vehicle, rather than a part of their self. For those individuals, there is medical help available to bring their bodies in line with their sense of self.
Anatomy is not as set in stone as you might believe. While some people with dysphoria might feel better with non-medical interventions such as binding or tucking, there are also medical procedures available which can go a long way towards alleviating dysphoria.
Anatomy is not as set in stone as you might believe. While some people with dysphoria might feel better with non-medical interventions such as binding or tucking, there are also medical procedures available which can go a long way towards alleviating dysphoria.
Standards of Care
There are two common medical interventions which can help dysphoria: hormones and surgeries.
Before we delve any deeper, let's talk about one of the most influential documents that guides providers in determining an individual's need for these interventions: the WPATH Standards of Care. WPATH stands for the World Professional Association for Transgender Health. This group of international experts in transgender healthcare has revised their original document 6 times since it was first published in 1979. Most doctors refer to the Standards of Care when treating transgender patients, and many insurance agencies consider the SOC when determining whether a procedure is covered. While there is always debate surrounding the Association's standards, they are generally regarded as the best evidence-based resource for treating dysphoria. If you are considering involving your provider in your transition, we suggest that you take a look through the Standards that apply to you if you are able. When it comes to your care, you are your best advocate.
Before we delve any deeper, let's talk about one of the most influential documents that guides providers in determining an individual's need for these interventions: the WPATH Standards of Care. WPATH stands for the World Professional Association for Transgender Health. This group of international experts in transgender healthcare has revised their original document 6 times since it was first published in 1979. Most doctors refer to the Standards of Care when treating transgender patients, and many insurance agencies consider the SOC when determining whether a procedure is covered. While there is always debate surrounding the Association's standards, they are generally regarded as the best evidence-based resource for treating dysphoria. If you are considering involving your provider in your transition, we suggest that you take a look through the Standards that apply to you if you are able. When it comes to your care, you are your best advocate.
Hormone Therapy
There's not a set order or timeline for every person's transition. Some people might need just hormones to feel comfortable, others might need just surgery, and others might need both. Each person's dysphoria is unique to them, and so treatment should be unique as well.
Hormones are often a first step towards feeling comfortable in your body, so we'll cover them first.
There are three kinds of hormone therapy: puberty blockers (a WPATH and FDA-approved treatment for children who haven't yet gone through puberty and want to delay it while they explore their options), feminizing and masculinizing. For people who want to look and feel more feminine, doctors can prescribe estrogen and sometimes progesterone. For people who want to look and feel more masculine, doctors can prescribe testosterone. Hormone therapy is a complex business, but in short, puberty blockers can delay puberty and potentially help a child avoid developing unwanted secondary sex characteristics, while feminizing and masculinizing therapy trigger a kind of "second puberty" for people who've already gone through a first, unwanted puberty. A person who went through a female puberty can take testosterone to drop their voice and develop facial hair and masculine muscle structure. A person who went through a male puberty can take estrogen (and sometimes progesterone or testosterone blockers) to develop breasts and feminine fat distribution. These are just some of the many life-changing effects of hormone therapy. If you are interested in any of these options, please contact Blue Mountain Clinic, or ask your provider if they have experience with hormone therapy (sometimes called Hormone Replacement Therapy, or HRT). In Montana, many doctors are not aware of HRT. If your provider has no experience but is willing to learn, suggest they consult with Blue Mountain's providers and the WPATH Standards of Care as an initial starting point.
Hormones are often a first step towards feeling comfortable in your body, so we'll cover them first.
There are three kinds of hormone therapy: puberty blockers (a WPATH and FDA-approved treatment for children who haven't yet gone through puberty and want to delay it while they explore their options), feminizing and masculinizing. For people who want to look and feel more feminine, doctors can prescribe estrogen and sometimes progesterone. For people who want to look and feel more masculine, doctors can prescribe testosterone. Hormone therapy is a complex business, but in short, puberty blockers can delay puberty and potentially help a child avoid developing unwanted secondary sex characteristics, while feminizing and masculinizing therapy trigger a kind of "second puberty" for people who've already gone through a first, unwanted puberty. A person who went through a female puberty can take testosterone to drop their voice and develop facial hair and masculine muscle structure. A person who went through a male puberty can take estrogen (and sometimes progesterone or testosterone blockers) to develop breasts and feminine fat distribution. These are just some of the many life-changing effects of hormone therapy. If you are interested in any of these options, please contact Blue Mountain Clinic, or ask your provider if they have experience with hormone therapy (sometimes called Hormone Replacement Therapy, or HRT). In Montana, many doctors are not aware of HRT. If your provider has no experience but is willing to learn, suggest they consult with Blue Mountain's providers and the WPATH Standards of Care as an initial starting point.
Surgeries
You may have heard someone refer to "the surgery" when talking about transgender people. Well, which one? I can think of seven different kinds of dysphoria-alleviating surgeries off the top of my head. Lots of parts of the body can feel dysphoric, from breasts to Adam's apples.
The kind of surgery that most people think of is Gender Confirmation Surgery, also called "bottom surgery," Gender Reassignment Surgery (GRS), or famously, The Surgery. There are many skilled surgeons who have devoted their careers to turning one kind of genitals into another kind. While no one has yet developed a method which allows a person to remain fertile, a person who undergoes Gender Confirmation Surgery usually retains the ability to experience sexual pleasure (and often this increases, because the person is no longer uncomfortable with their genitals). This surgery also allows people to "pass" as the gender they identify with better, but the most important reason for the surgery is not about feeling sexy or looking the way others think you should based on your gender: it's about feeling comfortable in your body. For an in-depth look at intimacy and genital dysphoria, we recommend Juno Roche's Queer Sex: A Trans and Non-Binary Guide to Intimacy, Pleasure, and Relationships.
But wait, there's more! A trans person might experience debilitating dysphoria about their genitals, but they might not. Either way, they might experience dysphoria about other parts of their body, sometimes even more than about their genitals. A masculinizing chest reconstruction ("top surgery"), breast implants, facial feminizing surgery (FFS), a tracheal shave (diminishes the Adam's apple), liposuction, and other surgeries can all be lifesavers for transgender people. For example, the author of this post experienced a dramatic increase in quality of life and reduction in depression and anxiety when I was able to receive a chest reconstruction and trade my D-cups for a flat chest. I didn't even realize just how much pain I was in until I had a frame of reference for what it was like to be without dysphoria. For the curious, the Western Montana LGBTQ+ Center has compiled a handy table of surgeries and information, which can be found at their Trans Health Resources page.
Surgeries are something to consider carefully. There's plenty of misinformation out there, so do your research. Google Scholar is a great resource for finding academic studies on surgeries. Read critically, and work with your provider if you think a surgery might alleviate dysphoria for you.
Financial Help
Probably the biggest barrier to care when it comes to transgender issues is funding. Some insurances understand the pressing need for treatment of dysphoria, and others do not. As with many chronic conditions, sometimes dysphoria forces you to become an expert on insurance policy. Fear not! You don't have to do this alone. Providers, including surgeons, often have insurance coordinators who will help you figure out whether your insurance will cover your care, and under what conditions. It's worth reading through your insurance policy, as well, and being persistent with companies who don't get back to you or give an insufficient answer the first (and second, and third) time. The truth is that many insurance agents simply aren't educated in transgender care and coverage yet, but this is changing. Contact [email protected] if you are a patient with Blue Mountain Clinic and have questions regarding coverage.
In addition to insurance, private foundations and charities are sources of funding that may be helpful. Transgender Pulse has compiled a partial list of some of these organizations that help with surgery costs. There are many others. An additional funding avenue that has helped many people is crowdsourcing campaigns, such as GoFundMe.
In addition to insurance, private foundations and charities are sources of funding that may be helpful. Transgender Pulse has compiled a partial list of some of these organizations that help with surgery costs. There are many others. An additional funding avenue that has helped many people is crowdsourcing campaigns, such as GoFundMe.