Beard hacks, finasteride hell, and 5 other things ‘trans masc’ folks might not know about.

Every so often — especially in transitioning — I’ll have one of those “why didn’t someone tell me this sooner?” moments. Because we’re in the age of information, I think a lot of folks in the transgender community just assume we already have the information we need.

But in actuality? Many of us don’t.

I’ve found that when I share some of what’s surprised me, there’s always a decent number of trans people who are also hearing it for the first time. While transition is a process of discovery, I can’t help but feel that life would be a hell of a lot easier if we did a better job of sharing what we’ve learned with others.

This article, then, is a mishmash of some of the clever, enlightening, or flat-out surprising things that I would’ve appreciated being told at the beginning of my transition.

As someone who is genderqueer — and more or less moves through the world as a “trans guy” — a lot of what I’m sharing here will be more relevant to folks on the “trans masc” end of the spectrum, though I do think there’s a little something here for everyone.

Not everything here will be life-changing information by any means, but I hope that at least a few things here will be helpful to someone who needs it.

1. There are (sneaky) ways to make your facial hair look less weird.

If Oprah gets to have her own “favorite things,” so do I, right?

If you read literally any guide about how to “pass” as a trans guy, they’ll tell you to shave your face. And as someone who had the misfortune of having much of their facial hair grow in thick but blonde (thanks, Dad), I get the impulse — my facial hair isn’t exactly uh, impressive.

The problem is, that little bit of facial hair? It’s often the deciding factor in whether or not my barista is going to misgender me, you know? So as counterintuitive as it may be, my beard has to stay, no matter how ridiculous and patchy it may look. Whenever I’m without it, I’m more dysphoric, and misgendered a lot more often.

We live in the age of makeup though, my friends. Drag kings have got this down to science, and I was fortunate enough to learn that there are ways to make your facial hair a little more… cohesive.

IMG_9223

Glossier’s “boy brow,” aka beard magic.

Drag kings often use mascara to create something of an imitation beard, but there’s actually an even better option for those of us who already have some facial hair and just need it to, you know, make itself known.

The brand Glossier (who hasn’t asked me to plug this or paid me to promote it in any way at all — I’m just eternally grateful that it exists) has a brow pomade called “boy brow” that helps make facial hair appear fuller, darker, and more filled in.

It’s subtle, but for the blonde hair on my face that refuses to show up, this has been a miraculous discovery.

I am never misgendered when I apply this to my face. It’s intended for brows, but it clearly has some benefits for trans folks like myself who need a little more “oomph” with their facial hair.

Observe the magic in action:

Screen Shot 2018-08-11 at 9.30.50 PM

Half of my face without “boy brow” (left), half where it’s used on my facial hair (right).

I’m personally using the brown shade that Glossier offers because it looks more natural on my face, though it does come in black as well!

If you look, you’ll notice that (1) I’m able to connect my sideburn completely, (2) my mustache is darker and has a more noticeable shadow, and (3) my beard has a lot less patchy weirdness to it.

I don’t necessarily apply this to all of my facial hair on a regular basis, but I did it here (apart from the parts of my face, like my cheeks, that I already shave regularly) just to give you an idea of what it would look like on each part of my face.

And it makes a lot more of a difference than you’d expect!

IMG_9227

The full effect, both sides! This is after a night out, so it lasts, I promise.

When I started doing this, a lot of people asked if I’d increased my testosterone dose, and no one was the wiser.

Not to mention, the misgendering really plummeted. All those “passing guides” that told me to go for the clean shave? They might’ve benefitted from knowing that this stuff exists.

But most importantly, I’m more comfortable. There’s this weird idea that using makeup to appear more masculine is somehow an unacceptable thing, but for me, it’s helped with my gender dysphoria and it’s changed the level of confidence I feel when I step out the door.

So before you shave your whole face in dismay, please know that this could be an option for you! Drag performers have been using mascara and brow pomade for ages, and it’s worth a try if having facial hair makes you feel more comfortable.

2. If you can’t find an LGBTQ+ therapist, you might be looking in the wrong place.

Real talk, having a therapist that’s in your own community makes a huge difference.

And you might be rolling your eyes and saying, “Well, OBVIOUSLY, Sam.” But I’m reiterating this point because I’m blown away by just how much of an impact this has had in my experiences with therapy.

Healing within your own community is a distinctly different thing from doing this kind of work with someone outside of it.

For the last year, I’ve been doing online therapy with a transgender and queer therapist. And that connection became even more important to me when, at the beginning of this year, one of my close friends (also transgender) died by suicide.

Having a therapist who knew what it was like to lose someone this way, and understood from a place of lived experience what queer grief is really like, became an invaluable part of healing for me.

I do know that therapy isn’t accessible to everyone, and it can be difficult to find a transgender or queer therapist on top of that.

But with the increasing accessibility of trans and queer therapists through online platforms like Talkspace (I wrote about this here), it’s worth investigating if you have the means. Some of these platforms even offer financial support, so click around and see what you can find!

3. Learning self-massage was the smartest thing I could’ve done for top surgery recovery.

Anyone who knows me can tell you that I am not athletic and am, by and large, a very sedentary person (which is a nice way of saying that I’m a couch potato). But when I discovered a local yoga class that used “therapy balls” to teach self-massage, I was uh, intrigued.

Because after top surgery, I was wound so tight that a massage sounded like exactly what I needed.

After top surgery, my body was kind of a mess — more than I’d really expected. A few months out, I still had very little range of motion. I had built up scar tissue and lumps and knots — especially on the sides of my chest, in my pecs, and between my shoulders — that I was convinced would be there forever.

Surgery is bodily trauma, you know? Even if it’s entirely wanted and amazing, we still have to heal after all is said and done.

So I started learning self-massage with therapy balls (my instructor uses the book “The Roll Model: A Step-by-Step Guide to Erase Pain, Improve Mobility, and Live Better in Your Body” by Jill Miller, but I’m sure there are others). My hope was that it would help me recover a little faster after surgery.

It definitely worked.

After a few weeks, I had regained full mobility and range of motion, including in my arms and shoulders. I am now even more flexible than I was prior to surgery. A lot of the built up tissue is entirely gone. The kicker? I’m only six months post-op at this point, and even my surgeon was amazed by how quickly I was able to recover.

A lot of people, as it turns out, use therapy balls and self-massage to manage chronic pain, as many of the exercises can be modified to suit virtually any body. Many of the techniques are exactly what a physical therapist would do with you in recovery — the only difference is that you’re using a tool to apply that pressure to yourself!

Google it, friends! Please! It’s something you can easily do at home, and while everyone’s body is different, finding ways to restore your range of motion after a major surgery is super important.

4. Binding your chest for a long time can affect top surgery results in some people.

Okay, I know, this should be common knowledge by now… but it definitely isn’t.

Apart from the documented (and expected) issues with binding — including pain, shortness of breath, overheating, that sort of thing — I actually didn’t know that binding could impact surgery results.

First of all, a disclaimer: Binding is critical and essential care for trans people, even with all risks taken into account. The relief it provided me from dysphoria isn’t something I would trade, even given all the nonsense I had to put up with during the years that I was binding and after.

But in the interest of transparency, I do want people to know that one of the lesser-discussed effects of binding your chest is the breakdown of breast tissue. Again, many of us know this, but we take on the attitude of, “Well, I’m getting top surgery later, so what does it matter?” (Hi, I thought that, too.)

But what I was surprised to find is that binding my chest impacted my top surgery results later on.

For those of us who go on to get a mastectomy, our tissue being broken down can affect our post-op results. Speaking for myself, as someone who opted to get nipple grafts, it became more difficult to construct them because that tissue was softer and broken down.

This means that some of us might notice that our nips look a little less distinct from the tissue surrounding them (in other words, they can wind up flatter than they might appear on cisgender men).

I am still thrilled with my top surgery results, but I think I would’ve opted for top surgery earlier had I known that the longer I was binding, the more that breakdown could affect the cosmetic results.

I was binding for about six years, so that obviously had a huge impact on the extent to which I experienced this. But it’s helpful to keep in mind if you’re trying to decide how long you should wait for surgery, or how often you should bind!

5. Testosterone exists in other forms besides injections.

I am realizing that not everyone knows this, so I’m including it on this list because I think it’s important. Time and time again, I hear trans folks saying, “I can’t start T because I don’t want to do the shots!” Lucky for you, there are options!

There are pills, though they can be kind of harsh for our bodies. More commonly, folks who are averse to giving themselves shots have the option of getting testosterone as a patch or in gel form.

I personally tried the patches and was allergic to the adhesive (fun times!). I have been using the gel for over two years now, and it’s terrific. It’s basically like hand sanitizer that’s a little thicker and has testosterone in it, and you rub it into your upper-arms and let it dry every day.

Super simple. No needles required!

6. Finasteride isn’t always safe — especially for trans folks with preexisting mental health conditions.

I talked about this quite a bit in this blog post, but it bears repeating. There has been some speculation that finasteride (otherwise known as proscar/propecia) can lead to suicidal thoughts in some people who take it, and some studies are showing that there are elevated risks of self-harm and depression when taking it.

It’s usually prescribed to slow down hair loss, which makes it a pretty common prescription amongst trans folks. But the reality is, its impact on trans people specifically hasn’t been studied much at all.

So, story time.

The only two times I’ve ever been psychiatrically hospitalized for suicidality came a few weeks after starting finasteride, with those episodes subsiding only after I discontinued it. I have never in my life experienced this level of depression and suicidality that I experienced while taking finasteride.

This is anecdotal, but there are many reports of others who experienced similar side effects that the World Health Organization is monitoring at this time.

Because all of these studies have only been done on cisgender men, we don’t actually know how it could impact transgender people, who are already more vulnerable to mental illness and suicidality.

All that said, what this means is that trans folks (or really, anyone) taking finasteride should proceed with a lot of caution! If you notice any increased depression or suicidal ideation, make sure you let your clinician know.

7. You can have gender dysphoria without realizing it.

I wrote about this at a pretty nauseating length in my open letter to truscum, but I’d like to highlight it a little bit here (and speak to, you know, the rest of us who aren’t transmedicalists), because I think it’s important information:

No one else saw me as ugly or ever said I was, but it was a feeling I couldn’t shake. I felt like, no matter what I did, nothing made that feeling go away.

I just thought it was a stupid teenager thing. Except that “stupid teenager thing” didn’t go away and I became a self-hating, uncomfortable, gross-feeling adult.

If you had met me when I came out in 2012, you would’ve said that there was no freaking way I was transgender. I knew I was miserable and I knew I hated how I looked, but “dysphoria” wasn’t a part of my vocabulary yet. While it had always been there on some level, I didn’t have any way to interpret what it meant.

And this isn’t an uncommon experience, trust me. Plenty of trans people come out and are still learning how to describe their experiences. For those folks, it’s sometimes much, much later on that they realize there was some dysphoria happening for them. Sometimes the label comes first — and that’s valid.

I didn’t grasp how severe it was for me until after surgery. Only when my dysphoria was considerably diminished did I understand just how heavy it was to begin with.

. . .

Some people also experience dysphoria only in the form of dissociation, or a state of unreality, numbness, or disconnection. They might not connect this to their gender at all, because it’s not an emotional state they can necessarily identify so quickly in the first place.

For trans people with other mental health challenges, trauma and mental illness might interfere with their understanding of their gender, and dysphoria becomes attributed to other causes (I also wrote about that here).

In other words, our brains work extra hard to try to protect us, which can make self-perception [of dysphoria] as a trans person a little wonky.

This is something that we, as a community, aren’t talking about nearly enough! Dysphoria is a very complex experience, and while we might not initially recognize it as such, there could be as many unique experiences of dysphoria as there are trans people.

So if you’re not sure that you’ve experienced dysphoria? That’s okay. Maybe you have and maybe you haven’t — or maybe you’ll understand it a little better with time. Your experiences are valid no matter what.

Transitioning is a learning experience, to be sure. Thankfully, it’s one that we can support each other through.

That’s why I love hearing from all of you in the community.

What are some things you wish you’d known sooner? What has been the most surprising part of transition for you?

Until next time,

signature

heart

This blog is not sponsored by any fancy investors or companies that are trying to sell you stuff.

It’s funded by readers like you via Patreon!

Every donation counts. Seriously. Throw a dollar my way, and help keep resources like these accessible to everyone that needs them.

Yes, I have a ‘mental disorder.’ But it’s not being transgender.

It seems like every other week, some conservative with a podcast and an ax to grind announces that being transgender is a mental disorder — despite having no credentials that would actually, I don’t know, make them qualified to diagnose someone.

And I’ll be honest — it’s frustrating to still hear this.

You don’t have to look very far to get the general medical consensus. The World Health Organization and American Psychiatric Association have both affirmed that being transgender is not, in fact, a mental illness.

And while “gender dysphoria” can be medically diagnosed, this is specifically done to access gender-affirming care — not because being transgender is in itself a disorder.

It’s true that some people really and truly don’t get it. There are some folks that use this kind of language because they don’t know how else to talk about the trans experience.

They don’t know exactly what a “mental disorder” is or what it’s like to be transgender. And they see that we’re suffering and dysphoric — so they don’t know how else to talk about it.

As someone who lives with obsessive-compulsive disorder (OCD) and also happens to be transgender, I can tell you upfront that there’s just no comparison.

Being transgender and having a psychiatric illness aren’t at all the same. Comparing them isn’t just an “apples to oranges” situation — metaphorically speaking, we’re not even in the same food group here.

And why is that? To start, let’s talk about what mental illness is.

The American Psychiatric Association defines mental illness as a health condition that impacts thinking, emotion, and/or behavior in a way that creates distress. More often than not, this leads to difficulty functioning in social, work, and/or family activities.

For people who aren’t transgender, they might look at this definition and come to the conclusion that trans people are mentally ill, because many of us do experience distress, and being transgender absolutely does impact how we think about ourselves and how we behave.

The problem is, it’s not being transgender that, in and of itself, creates distress and dysfunction. It’s the difficulty in trying to be who you are when the society around you is deeply hostile towards you.

It’s not my gender identity that’s caused me distress. It’s moving through the world as a trans person.

If anything, identifying this way has brought me enormous relief and made me a happier person overall.

I started to experience distress because of how others treated me. I was distressed when I experienced invalidation, harassment, and rejection. I was distressed when I was closeted, trying to be something that I wasn’t.

And my functioning was impacted when I couldn’t access care, like hormones and surgery.

When I wasn’t able to be who I was, and when I encountered violence and opposition because of it, that’s when I was distressed.

When someone is suffering as a result of how the outside world treats them, especially when they are part of a group that has historically been marginalized, that’s not a mental disorder.

The word you’re looking for there is “discrimination.”

The more “insane” thing to do would’ve been to keep pretending to be someone I wasn’t, which was a much more agonizing experience for me.

Figuring out my gender wasn’t a problem. In fact, it was a huge relief and it improved my life, so long as society did not interfere with my ability to transition. I’m far more mentally healthy now than I ever was prior to transition… by a long shot.

And that’s why I consider my experiences with obsessive-compulsive disorder and my transgender identity to be — categorically — two very different things.

It’s true that how society treats me because of my OCD, and a lack of accessibility to the therapies and medications I needed to thrive, were both contributing to my distress. Discrimination happens to people with mental illness, too, and it can have a profound impact on our lives.

But there’s a component to my distress that originates outside of that mistreatment.

OCD — and the neurobiology behind it — creates patterns of thought, emotions, and behaviors that are in themselves distressing, even under the very best circumstances.

Labeling those patterns as a disorder is the quickest way to say, “There are aspects of my biology and brain chemistry — mixed in with my environment and genetics and everything that makes me a human — that create specific and unpleasant mental/emotional experiences for me.”

Those patterns have been studied over the years, and they’ve been observed in many people who all respond similarly to particular solutions. The label exists to guide people like myself to the resources and solutions that will help reduce our suffering.

Many of these mental and emotional patterns associated with OCD feel at odds with who I am, and when I don’t work to mitigate their impact, my mental health worsens.

Being transgender, though, feels in alignment with who I am, and when I am able to freely explore and express this part of myself, my mental health improves.

The unpleasant experiences that stem from OCD aren’t reflective of who I understand myself to be; I feel more “myself” in the absence of those experiences.

As a transgender person, though, I feel more “myself” when I am able to embrace my gender identity. The more present I am in that experience, and the safer I feel in expressing that, the more whole I feel.

To call my transgender identity “disordered” implies that I need to minimize this part of my experience, but to be the very best (and healthiest) version of myself? I need the exact opposite.

The key differences here, then, are where that distress is coming from, and under what circumstances it improves.

Those two factors are where being transgender and being mentally ill diverge completely.

I don’t experience distress when I think about being a gender other than what I was assigned at birth, and I don’t experience distress from behaving accordingly. In fact, the more freely I am able to live my life in ways that align with my identity, the healthier I am.

But I do experience distress when I think, behave, and feel things as a result of the neurobiology we call “obsessive-compulsive disorder.” And the more I’m able to minimize and manage the impact of those thoughts, behaviors, and emotions, the healthier I become.

In that way, these are totally opposite scenarios.

When we diagnose someone, we’re essentially saying, “This pattern is present, but if it were less so, this person’s mental health would improve.”

So when you say that being transgender is a mental illness, you’re saying that suppressing or minimizing that identity would then lead to mental health.

But this simply isn’t the case. When trans people are able to be themselves and access gender-affirming care, their mental health outcomes are often better. This is especially true in situations where discrimination or violence is less likely, or in the case of youth, when they are supported by their families.

So by its very nature, being trans cannot be a mental illness — because invalidating and minimizing a trans person’s identity has not been proven to positively affect their wellbeing.

It’s the complete opposite.

If you were to classify being transgender as a mental illness, then, you would be making a recommendation to a clinician to treat us in a way that would not improve our health, which completely defeats the point of making any diagnosis in the first place.

But there are plenty of trans people who continually emphasize how much these attitudes harm us.

We don’t need transgender people to stop being trans, nor do we need to further stigmatize our identities and experiences. Gender diversity is not an illness — a society that is hostile towards it, though, is far more distressing.

If diagnoses are meant to help improve a person’s health, I’m still waiting to see any proof that labelling us mentally ill is actually improving our lives.

The sad reality is, many of the people who still insist that being transgender is a “disorder” don’t actually care about our mental health.

Because let’s be honest, if they did? They’d stop talking and do a much better job of listening.

People who are determined to label transgender people “mentally ill” — those who do so to rile people up on Twitter, not just because they haven’t thought about this much — do so because it’s a way of dehumanizing us.

It’s a way of suggesting that we are delusional and that we aren’t who we say we are. It implies that trans people need to be “cured” or “fixed,” and that we shouldn’t exist. To them, we’re mistakes that never should have happened.

That mentality is used to justify a lot of the emotional and physical violence that wounds and even kills us, and it perpetuates the hostility and self-hatred that drives so many of us to suicide.

But I want to be crystal clear about something: my being transgender was never a mistake.

My path hasn’t been an easy one in a lot of respects. But the strength and determination that I carry in my heart is part of a legacy — it comes from generations of transgender and gender nonconforming people, those who were willing to risk everything for a future they knew they might never see.

They stared down all of the dangers that came with that, showing up for each other and for a better world, so that one day, trans people like me could truly live. It’s a legacy that I now have the privilege of inheriting, and it’s one that I don’t take for granted.

For me, being transgender is an honor — and every single day, I step into my life knowing that from the moment I was born, I arrived with a purpose.

I want a future where every trans person can become who they are with every ounce of safety, love, and affirmation they deserve. And if that’s your definition of “crazy,” it sounds like I have my work cut out for me.

Challenge accepted.

signature

heart

Let’s connect! Join me on Patreon for more exclusive content. Access my new video diary, join my monthly writing workshop, vote on what I write about next, and so much more! It’s a great way to show your support for the blog and keep these resources accessible (and, y’know, become best friends).

Need a therapist? If you follow this nifty link, you can get $50 off your first month of therapy with Talkspace. Not a bad deal! ¯\_(ツ)_/¯ Read more about online therapy with Talkspace here.

 

Photo by Francisco Gonzalez on Unsplash.

This is what I wish people who identify as ‘truscum’ would try to understand.

This is an open letter to transmedicalists.

I’m being direct this time, because I don’t want to talk about you as if you are some faraway, distant other. I don’t think that helps anything. You’re real people, and no matter where we differ, I don’t want to forget your humanity.

I’ve talked in the past about harassment that I’d experienced years ago from trans folks who identify as “truscum” (so, for outsiders, transgender people who believe gender dysphoria and medical transition are necessary to identify as trans — otherwise known as transmedicalists).

Most recently, I took to Twitter to vent about it. And, not surprisingly, a lot of you weren’t super happy with me about it.

Your responses got me wondering if I could’ve done things a little differently. Because I’ll be honest — I don’t know that it ever occurred to me before then to speak to you directly.

I’m not going to pretend that I’m not angry or hurt. But I don’t hate you, as some of you suggested. I just really, really want you to stop hurting other trans people.

Based on your responses, though, I wonder if you even realize that you’re harming anyone. I think you’re caught up in some of your own pain, too, and that doesn’t make this conversation easy for anyone.

So I’m taking a deep breath and doing what I should’ve done in the first place — unpacking, very carefully, exactly what I’m struggling with. I’m going to explain as best I can why this “truscum” thing is upsetting for me as a trans person.

And I want to give you the benefit of the doubt, because even if you don’t see me as part of your community, I still believe that you’re part of mine.

Relentless optimist that I am, I like to think that someday trans folks might join hands around a campfire singing “Landslide” by Fleetwood Mac (I swear this song is a transgender anthem — just a personal, unrelated opinion of mine).

But I’d be pleased if we were just nicer to each other as a whole.

This is the longest blog I’ve ever written by far (sorry in advance). But if you’re wondering if I’m coming from a genuine place? Rest assured, I wouldn’t expend this much energy if I didn’t care about this very deeply.

If you’re rolling your eyes about how exhaustingly long it is, you can also bookmark it at any point and come back to it. It’ll still be here. And I’m breaking it up with headers, so hopefully it’ll be easy to find your place again.

So why am I even talking to you in the first place? That’s a valid question.

To understand why, you’ll need to know a little bit of my history.

The first thing you need to know is that I work in digital media. It’s important to mention this upfront, because it’s my public work as a transgender writer that got the attention of transmedicalists in the first place.

Back in 2015, I started receiving emails and tweets from self-identified “truscum” for a blog that I wrote about how much I hated the word “transtrender.”

I didn’t believe that the stance I took was especially controversial — but it drew a lot of attention to me as a trans person, and led to some targeted harassment, which continued for a while throughout my career.

The fact that I hadn’t yet medically transitioned led these folks to start asking invasive questions about my body. They were barging into unrelated conversations on social media to tell folks I was an imposter, contacting my followers with conspiracy theories about my transition (I’d made it all up apparently), and otherwise trying to discredit my work.

And of course, I was misgendered. Just to add a little salt to the wound, I guess.

The reality is, at that point, I’d never said I didn’t want to medically transition. It was that I couldn’t.

Initially, in 2014, I’d had issues with my insurance because I’d moved across the country. After that, it was my mental health status that led clinicians to deny me access to transition-related care (if you’re curious about how this nightmare happens, I interviewed other trans folks with similar experiences, and I wrote about it here).

So while this harassment campaign was happening, I was privately struggling with dysphoria that I could do literally nothing about. You’d hope that other trans people would see this as a rallying cry to demand better access to care. But these folks didn’t.

Instead, transmedicalists told me my lack of medical interventions made me invalid.

In a word? It was traumatic. I felt betrayed by my own community; I thought if anyone was going to understand my struggle, it would be other trans people.

It didn’t stop when I finally accessed hormones, either. Instead, transmedicalists had decided I was lying about that. When I posted a photo of me holding my testosterone gel, they suggested it wasn’t my prescription, and then they decided that because I hadn’t had surgery, I still couldn’t be believed either way.

Never mind the fact that I was desperately trying to access care the entire time.

These were my very first experiences with “truscum.”

I’ll be honest — never in my wildest dreams did I think that the folks harassing me would be other transgender people.

And it wasn’t just me, either. I watched this happen many times to others as well, including some of the advocates that I deeply respect and young trans folks who had only recently come out.

So I’ll just be upfront and say… you all didn’t exactly make the best first impression.

And I know, I know. You might be thinking, “But that wasn’t ME! I didn’t harass you! What has this got to do with me?”

I understand why the generalization might bug you.

But when you tell someone that they have the ability to determine who is and isn’t transgender, some people will use that mentality to justify some really abhorrent behavior. Whether you’re passively advocating for that or actively doing so, the ultimate result is that people then feel emboldened to play “gender police.”

They feel emboldened to decide who is and isn’t “trans enough.” And that means people get hurt.

That’s the crux of the issue for me. Regardless of what you’re intending, people are getting hurt.

And I have yet to see folks who identify as transmedicalists acknowledge that this is happening, and that there are valid concerns here.

If you’re still with me here — and if you are, I appreciate it — I want to explain to you exactly why transmedicalism as a concept is so troubling to me, with the hopes you can better understand the pain that I’m talking about.

Not because I want to lecture you or that I think you’re incapable of googling this. It’s just that I recognize it’s possible that folks just didn’t take the time to unpack it in a way you could hear it, and instead they became reactive in a way that felt dehumanizing to you.

So let’s establish my starting place (or bias, whatever) here: It’s true that I don’t believe the presence of dysphoria is necessary to identify as transgender.

I understand that from the get-go, that can touch a few nerves. But I want to explain why I think that’s an important place to start from, regardless of how it makes either of us feel.

I stand by those points in part because I don’t think dysphoria is a helpful measure in the first place — which I’ll explain in a moment.

I don’t say this because I don’t understand the knee-jerk reaction that can happen when someone says they haven’t been dysphoric. Because yeah, dysphoria is painful. It sucks. When I got my first rejection while trying to access top surgery, I began abusing alcohol to cope — it was not a fun time for me. The pain nearly killed me.

I know it’s hard to imagine someone as trans when they don’t understand that kind of pain, especially when it’s a pain you’ve known acutely for a very long time. I’m with you there.

I’ve reacted that way before, too. I’m human. Sometimes my first reaction to something isn’t always my kindest one.

In a perfect world, we would have some reliable indicator or litmus test for helping folks to figure out if they were trans or not — some singular measurement that erases all doubt. As a fan of simplicity myself, I get the appeal.

But the reality isn’t so simple — many trans people suppress those feelings of dysphoria, or they misinterpret them and struggle to connect them to their gender.

This can make it impossible to discern — especially as an outsider — if dysphoria is present. Requiring dysphoria to identify as transgender, for that reason alone, has way too much room for error.

A personal example: I’ve actually experienced some level of dysphoria for my entire life… I just didn’t know initially what it was.

I don’t want to do a deep dive into my history here, but suffice to say, the background that I came from made it very difficult to question my own gender safely.

So I experienced dysphoria, instead, as feeling profoundly self-hating and “ugly” (I wrote about this previously in this article, if you’re wondering). No one else saw me as ugly or ever said I was, but it was a feeling I couldn’t shake. I felt like, no matter what I did, nothing made that feeling go away.

I just thought it was a stupid teenager thing. Except that “stupid teenager thing” didn’t go away and I became a self-hating, uncomfortable, gross-feeling adult.

If you had met me when I came out in 2012, you would’ve said that there was no freaking way I was transgender. I knew I was miserable and I knew I hated how I looked, but “dysphoria” wasn’t a part of my vocabulary yet. While it had always been there on some level, I didn’t have any way to interpret what it meant.

And this isn’t an uncommon experience, trust me. Plenty of trans people come out and are still learning how to describe their experiences. For those folks, it’s sometimes much, much later on that they realize there was some dysphoria happening for them. Sometimes the label comes first — and that’s valid.

I didn’t grasp how severe it was for me until after surgery. Only when my dysphoria was considerably diminished did I understand just how heavy it was to begin with.

It was a kind of misery I was accustomed to, to the point where I was the fish in the bowl that couldn’t really see the water. You know what I mean? But now that I’m post-op, it’s like I’ve experienced a kind of joy and ease that I didn’t know was possible.

There’s also folks for whom their feelings of dysphoria progressively appear or worsen overtime.

I think of this as a kind of “hibernation.” People suppress all kinds of emotions, and dysphoric ones aren’t some magical exception. But as they start to experiment with language, and explore their identity and expression, those feelings start to surface. As the outside world begins to reject them, that can trigger those feelings they’ve managed to push down as well.

Some people also experience dysphoria only in the form of dissociation, or a state of unreality, numbness, or disconnection. They might not connect this to their gender at all, because it’s not an emotional state they can necessarily identify so quickly in the first place.

For trans people with other mental health challenges, trauma and mental illness might interfere with their understanding of their gender, and dysphoria becomes attributed to other causes (I also wrote about that here).

In other words, our brains work extra hard to try to protect us, which can make self-perception as a trans person a little wonky.

That’s what brains do with any kind of trauma. And this can show up as a total break from our own sense of dysphoric feelings, or misunderstanding the source or nature of those feelings. It’s more common than you’d think.

So when a trans person says they don’t experience dysphoria? It might be their truth at that particular stage in transition. But that doesn’t mean it always will be. Those feelings could surface in the future, become better understood and recognized overtime, or progressively appear as it becomes safer to process them.

But if we accuse trans folks of being imposters from the start, we might closet them before they ever figure any of that out.

So for me? One of the big problems with transmedicalism as a concept is its potential for “friendly fire.” When you use dysphoria as this “infallible” meter stick, you actually end up excluding a lot of trans people who are traumatized or vulnerable, and arguably most in need of support, especially if they’re emerging from denial or dissociation.

Transmedicalists are more likely to harm someone who is trans than successfully cast out an “imposter.” Because in actuality, more of us are traumatized than faking it.

When I first came out, I said that I didn’t want hormones and I wasn’t sure I wanted surgery. I am definitely the kind of “transtrender” that you would’ve rallied against (and, well, you did for a while).

Looking back, I have to laugh out loud. I can’t imagine not having medically transitioned.

With proper mental health care and, yes, incredible community support, I was able to get to a place where I could identify this resistance as a fear of rejection by society and my family especially. I was in deep denial because I was afraid of what would happen if I transitioned.

I didn’t want to lose my family. So instead, I lost myself. It took a long time (and a lot of support) to really come to terms with that.

That’s the thing, though: I needed space, support, time, and compassion to be able to figure out my path.

As of 2018, I’ve been on testosterone for a few years now, which drastically improved my life and my mental health. And I’ve had top surgery, which was the single best decision I’ve ever made. I am so much healthier and happier now.

But when you use a singular measure like dysphoria to decide if someone is worthy of those things, you run the risk of doing a lot of harm to folks who aren’t “faking” anything — folks like me who needed to process things before they could make the right choice.

And there are plenty of reasons why medical transition isn’t an easy decision, too.

Some people can’t access it for financial reasons or are denied access by clinicians. Some folks have chronic illnesses that would make medical transition risky or undesirable. Some folks might consider it safer to remain closeted. Some folks are in abusive environments where they can’t even begin to contemplate something like this.

And for some folks, right here and right now? They just don’t want to or aren’t ready to.

Maybe they’re questioning, maybe they’re afraid, maybe they’re overwhelmed, or maybe they’re just fucking tired. That could change and that may not… but it’s not up to us.

It’s not our business why and it’s definitely not our place to interrogate them, especially because we run the risk of doing serious harm for folks who might be going through some shit — shit that maybe they don’t even understand yet and can’t articulate.

You just. Never. Know.

It’s kind of like that quote, about how everyone is fighting their own battle. Even if it’s a battle you can’t see — because with trans folks especially, it’s the battles we can’t see that most often define our experiences.

So listen, I’ll give you this: Some disagreement over how we define “transgender” is bound to happen. It’s not the disagreement part that I necessarily take issue with.

It’s miraculous (and incredibly rare) that anyone agrees unanimously about anything. There are some people, for example, who don’t like Nutella, and that I will literally never understand. The difference here is that when someone tells me they don’t like Nutella, no one is actually being harmed in the process.

I acknowledge that there are going to be growing pains for our community, and I think this is part of that. These aren’t the first pains, and they won’t be the last. Historically, in every community ever, there have been divisions and disputes.

What I’m questioning here isn’t the definition of transgender. It’s what actually happens in the real world when we rely on your definition specifically.

Using dysphoria or medical transition as the way to define transness results in gatekeeping — and gatekeeping doesn’t work, because it’s too easy to get it wrong. And when we get it wrong? Trans people get hurt. Period.

The people who end up hurt most often (like, overwhelmingly so) aren’t actually faking anything and just wouldn’t benefit from doing so.

I was one of those trans people when transmedicalists harassed me in 2015. I was struggling to identify and understand my own dysphoria. I was being denied access to gender-affirming care by clinicians. I was struggling with PTSD and mental illness.

It was a battle you couldn’t see, and instead of offering empathy, I was harmed by folks who should’ve stood by me.

Are there trans people who haven’t experienced dysphoria and never, ever will? There could be.

Regardless of what you think, I’m not convinced that the existence of trans folks who don’t presently experience dysphoria is justification for disbelieving people who come out of the closet.

Those folks might want to access transition-related care in the future anyway, because it could make them happier or healthier. They might uncover that they have been dysphoric as they learn more and gain more hindsight.

Which means that either way you slice it, you can’t know for sure if someone is transgender or isn’t, even by your own definition — because people change and grow all the time.

Otherwise, I apparently wasn’t transgender in 2012 but I was in 2014. I wasn’t transgender when I was too traumatized to grasp it, but I was when I was able to access and process my emotions. Which… doesn’t make any sense.

Personally? I think gender identity is a diverse and complex thing — which to me is pretty exciting — but we might never agree there, I realize.

But you don’t have to understand their experience to respect their process.

Folks need to be able to explore their gender identity without hostility, because we simply don’t know their internal reality and we never will. The paradoxical reality is that the more fiercely you try to keep “outsiders” out of the trans community, the more likely you are to hurt trans people.

It’s not effective. It’s not helpful. It serves no other purpose than to hurt people.

So if someone says they’re transgender? You should believe them (or at least leave them alone, okay?), no matter how you choose to define “transgender” at the end of the day. The risk of driving a trans person deeper into the closet is simply too great.

It’s far more important to make sure that anyone who is questioning their gender has options and support, and that those options are protected no matter what, than trying to suss out who does or doesn’t “belong.”

So the moment they say “I’m transgender,” I congratulate them and I move on. What the hell do I know? That’s between them, their support network, their therapist, and whoever else they choose to involve.

Otherwise, there’s too good a chance that a transgender person who needs support will be denied it, just because of a misguided assumption about how they’re presenting in a particular moment.

We already get that from cis people constantly. Let’s not be like them, okay?

That’s why, when I define transgender as “identifying as a gender other than the one you were assigned at birth,” I do so with very intentional openness.

I want to be inclusive of folks who are questioning, and I want to give folks permission to evolve or change their minds, because that’s the only way to ensure that trans people can make the choices that are best for them.

The reality is, very few trans people emerge from the womb with an immediate and full understanding of their identity.

But people don’t make awesome choices when they’re being shouted at or put on the defense. Or in my case, harassed. Transitioning within a community that feels like a pressure cooker, demanding a particular kind of conformity, is never going to lead to the best possible outcomes.

And honestly? Asking trans people to put the horse before the cart — to know what they need and who they are before they can entertain a label — isn’t how a lot of folks actually operate.

The label is often what connects folks to more information, support, and self-discovery. It helps them uncover what they’ve suppressed and who they might become. So being possessive over the label actually winds up failing a lot of folks in the community, because they need the language before they can find a framework to operate from.

I want to say, too, that I understand it might be hard to let go of that impulse to judge.

When we identify with our struggles, it can feel insulting when someone who hasn’t struggled in the same exact way takes on a label that has so much meaning to us — a label that you feel you’ve earned, while others seem to just be sauntering right up and grabbing it.

Even so, I think we need to all agree — at the very, very least — that this is much more complicated than simply walking up to a label and dropping it into your identity shopping cart.

We’re talking about psychology, culture, language, trauma, biology, intimacy, sexuality, even spirituality — what aspect of the human experience is gender NOT touching on? And that’s ultimately why I think reductionist definitions fail us as a community.

Gender is messy and abstract. If it weren’t, we wouldn’t be debating it literally all the damn time. The very fact that we don’t agree on this is simply proof that this is a complex thing we’re dealing with here.

And for that reason alone, I recognize that we will probably never agree 100% on what it means to be transgender. But I don’t think we have to — we just need to agree on how to treat one another.

You know, with respect.

So what do we do, then? For me, I’m just trying to do the least amount of harm. I’m asking you to consider doing the same.

There are so many different paths that people take to arrive at an understanding of themselves.

But if we close the door too swiftly on people who aren’t exactly like us, we run the risk of shutting the door on someone who needs us — someone with whom we might share a lot more in common with than we’d expect.

Personally, I don’t think people choose to be trans in a world that isn’t terribly kind towards trans people. And even if they did put on some kind of weird act, I’ve accepted that I can never know that for sure, nor can I really do anything about it.

But I can be kind and gracious with the hopes that, wherever folks end up, they find the path that’s right for them. Extending that kindness to them doesn’t harm me in any way, shape, or form.

At the end of the day, it’s more important (to me, anyway) to create a community that allows trans folks to thrive. Gatekeeping doesn’t allow for that — it makes us suspicious of each other, callous, and combative.

If we want trans people to be able to come out, we have to make our community a safe enough place for them to do so.

When I came out in 2012, I had so many incredible trans folks to look to, and I owe so much of my happiness and health to them now. If I hadn’t had their support, I would still be closeted, if I’d even be alive today.

Every person deserves the chance to question their gender and explore it freely, without pressure, harassment, or gaslighting. This isn’t just a “be nice” issue — this is about the mental health and resilience of this community.

And I so badly want to believe that the majority of transmedicalists don’t actually approve of the harassment that folks like me have experienced, and don’t want to see what happened to me happen to anyone else.

I want to believe that if they knew the full story and really thought it through, they would’ve been there for me, as a trans person who knows how hard it is to be trans.

But the only way to guarantee that we aren’t caught in the snares of gatekeeping, and harming one another, is if we end this culture of interrogation altogether.

When in doubt, we need to do the kind thing instead, and let people live. You may not understand where they are in their journey right now, but they deserve the freedom and dignity to walk that path and see where it leads them. They deserve all the time and space they need to figure it out.

They may or may not continue on that path — but it’s not for us to decide.

I’ve given you all the benefit of the doubt here, because I believe every one of us deserves it.

Will you please extend the same to other folks in this community?

signature

heart

Appreciate the blog? Please consider becoming a patron! A dollar a month might seem small, but it helps keep this labor of love going.

Need a therapist? If you follow this nifty link, you can get $50 off your first month of therapy with Talkspace. Not a bad deal! ¯\_(ツ)_/¯ Read more about online therapy with Talkspace here.

Photo by Josh Wilburne on Unsplash.

People-pleasers can be drawn to toxic relationships. It’s important to know why.

I’ve learned in life that when you observe a pattern about yourself, it might be worth examining (okay, this is an understatement — I can pretty much guarantee you that you’ll come out wiser).

One of my big “aha” moments this year was around a relationship pattern that I hadn’t noticed before. I realized that I’m a people-pleaser.

Being liked by others, especially in my personal life, came at the expense of voicing my true feelings and needs. It was more important to be liked than it was to have relationships that felt honest and nourishing.

And it’s a lonely place to be — it can feel like no one knows your true feelings or self, and that you are secondary in relationships that should feel equal. Unsurprisingly, this can lead to a hell of a lot of resentment.

And thus… a pattern emerged.

My favorite kind of person to love was someone I had to chase — the kind of emotional inaccessibility that, in my mind, was a love I had to “work for.”

I didn’t like love if it felt easy. I didn’t like love if it was readily given to me. The love and affection that I valued the most came from people who were withholding, because my self-worth was defined by “earning” love, rather than feeling inherently worthy of it from the start.

Is this sounding familiar?

The flipside of this, of course, is that I was quick to avoid people who immediately cared for me, and who offered their love freely and readily. I was more likely to run from someone genuinely caring than I was from someone who treated me poorly.

I avoided the people who gave me the kind of love I wanted, because it scared me, and I was sure that I would disappoint them with time. I thought they must be mistaken — I hadn’t yet done anything “worthwhile,” and so I was reluctant to believe them when they told me that they cared. It didn’t feel deserved.

So instead, I threw myself at the people who were inconsistent or withdrawn, because I found their distance to be safer, more believable, and in some ways, more fulfilling. Each time they finally reciprocated, it felt like a special kind of reward, reserved especially for me.

But that pursuit of approval meant a lot of the relationships I invested in were also toxic by my own design.

I was more concerned with approval than honesty. I was quick to “mirror” — saying what I believed I “should” say, deferring to someone else’s opinion even if I didn’t share it, and avoided being disliked at all costs, even if the end result was being disingenuous.

I would rearrange myself for a person if it meant these distant, withholding people might love me back. I’ve done this all of my life — and at times, it’s made me pretty miserable.

I became someone I disliked a lot of the time, but for a while, it was easy to overlook this as long as I had some special person’s approval or praise. My opinion of myself didn’t matter as much as the opinions of other people — and the more emotionally unavailable and authoritative I perceived them as being, the more their opinions seemed to matter.

For years, I didn’t even consciously realize that I was doing this.

The unnerving thing is that people-pleasers, because they so often defer and try to appease, can often attract very controlling people.

This actually makes sense if you think about it.

Someone who always wants to “win” will obviously enjoy (and even exploit) the company of someone who always lets them.

People-pleasers are more than eager to offer someone whatever it is they want — praise, attention, investment — to feel valued, while controlling folks thrive from the safety they feel from being able to offer or revoke their affection at any time.

That, in turn, creates a power dynamic. The people-pleaser is trying endlessly to earn “love” to sustain the feeling of worthiness, while the controlling person decides whether or not to offer that to them in return.

They can withdraw their approval at any time. This means they can choose when to be pursued to regain a sense of control, simply by giving or withholding love. This can be used in manipulative ways.

And often times, neither party involved actually realizes what’s happening. They’re both just pursuing what makes them feel safe. The people-pleaser is pursuing approval, and the controller is seeking, well, control.

As it turns out, this is a documented phenomenon — psychologist Shirley Vandersteen actually writes about the pleaser/controller relationship archetype at length. If you’re a people-pleaser like me, it might sound more than a little familiar.

Reading this, I was pretty convinced that Vandersteen must’ve met all of the ex-boyfriends I’ve had since age fifteen. Yikes.

The thing that’s important to remember, as Vandersteen explains, is that both people-pleasing and controlling can come from family of origin trauma.

I would take that a step further, too. I know many queer and trans people who were so fearful of rejection, they took up people-pleasing as a survival strategy, simply to cope with that fear. This is especially true of queer femmes, who are already conditioned to appease and offer emotional labor in this unreciprocal way.

If you internalized any kind of homophobic or transphobic self-concept, you might’ve found yourself overcompensating in other ways. If the world wasn’t going to accept your identity, you might’ve strived to be acceptable or even perfect in any other capacity that you could be. This offers an illusion of self-protection (the logic here being something like, “if I’m ‘good enough,’ maybe they’ll still accept me”).

The problem is, if this mentality goes unchecked, you’re likely to chase after a kind of love that just isn’t healthy or sustainable because it’s all you really know to do. You’ll be reenacting that trauma indefinitely until you learn to interrupt it.

At least, I was. The only kind of love I knew how to pursue or accept was one in which love and investment was currency — a kind of currency I had to work for, a reward for proper or desirable behavior. But this meant that I was rarely honest about my feelings, my needs, or my desires.

People-pleasers wind up giving up their autonomy in the process, too.

The pursuit of being “good enough” means that the other person holds all the cards — making your self-worth, security, and support entirely reliant on how that person feels on any given day. It’s not reciprocal. And more than likely, it doesn’t feel so great, either.

Worse yet, it opens us up for a type of abuse that is very difficult to step away from. The second a carrot of affection is dangled in front of us, the approval can be alluring enough to get us back on the hamster wheel again, and again, and again, without recognizing the true toll that it takes.

Even if that means getting hurt or never receiving the kind of love we actually want in our lives, the chase sustains the illusion that we might someday have it if we just try hard enough. It’s a comforting thought, but this is rarely (if ever) the case, because the people we’re chasing after are often the least likely to give us the love we’re actually looking for.

Here’s my advice: If any of this rings true for you, it’s time to get honest about it.

At the beginning of this year, working with a trauma-informed therapist (who is just fabulous) meant that I took a long, hard look at the ways in which I approached love and intimacy. And if you couldn’t tell from what I’ve written here… I uncovered some shit. Some really alarming, scary shit.

There’s no magical step-by-step guide that will help every individual person with these tendencies (everyone’s journey is unique — especially when it comes to trauma).

But I can share from personal experience what’s helped me. I’ll even condense it into nice bullet points, just to get you started:

  • Seek out trauma-informed care. I’m a broken record here on this blog, but therapy can be, well, therapeutic. I’ve actually found online therapy to be incredible in this regard. I am less concerned about my therapist on the other end because of the distance between us — so I’m actually more honest. I wrote about my experiences with online therapy here, if you’re interested.
  • Read up about complex trauma, especially related to families of origin. Pete Walker has written at length on this subject. His book, Complex PTSD: From Surviving To Thriving is an incredible resource, and I consider it to be one of the most important books ever written on this subject. If you’re not sure if you are “traumatized enough,” I wrote about that in this advice column. Self-knowledge really is power.
  • Approach your relationships mindfully. Sometimes we become so concerned about how others feel, we lose all awareness around how a particular relationship makes us feel. If you suspect that you struggle with people-pleasing, pay particular attention to how you feel after your interactions with the people you’re close to. Spoiler alert: You shouldn’t feel worse.
  • Look for the signs. Red flags can include feeling like a relationship is one-sided, feeling powerless, or even controlled. You might feel lonely, as if you can never say “no” or voice how you truly feel. You may notice that you’re rarely the person making decisions, that you’re a doormat, or that you cave more easily than others. You might even feel resentful, as though you aren’t getting what you want but it’s too frightening to ask. Guilt and self-blame can be really common, too, because we often attribute a relationship’s failures to our own shortcomings.
  • Take it a day at a time. Practice saying “no.” Practice vocalizing what you want or need. Validate that it’s okay to say things like, “I disagree,” “I wish I could help, but I can’t,” and “this isn’t working for me.” Take note of those moments when you say something for someone else’s benefit or happiness rather than how you truly feel. And above all else, be compassionate with yourself.
  • Stop avoiding the people who are generous with their love — even when it’s scary and even if you feel you don’t deserve it. For me personally, the biggest change I had to make was investing more in the relationships with people who didn’t hesitate to offer love and encouragement to me. I stopped avoiding their texts. I took them up on their invitations. I kept reaching out, even when it scared me. My life continues to get better and better, simply by inviting these folks into my life.
  • Take accountability. Realize that your relationships can only grow if you choose to be authentic. Recognize the ways in which you might reinforce unhealthy dynamics when you aren’t honest about your feelings. Exempting abuse, we can rob a relationship of its full potential if we aren’t being accountable for how we show up.

People-pleasing is often a survival strategy, and an understandable one at that. Thankfully, it’s one we can learn to push back on.

I genuinely believe that just recognizing these patterns in our lives can help us break out of them. And while it can be a painful process, I can honestly say it’s one of the best things I’ve ever done for myself.

Each and every one of us deserves healthy, affirming, and reciprocal love. And if you haven’t heard this recently, I’d like to remind you that you’re already worthy, exactly as you are. Don’t let anyone — past or present — convince you otherwise.

signature

heart

  • Appreciate the blog?  Please consider becoming a patron! A dollar a month might seem small, but it helps keep this labor of love going.

 

Photo by Perchek Industrie on Unsplash.

Transgender people shouldn’t have to lie about their mental health. But many do.

Until this last year, accessing top surgery was a losing battle for me. But it’s not because of where I live, my health insurance, or any of the other typical barriers you might imagine when trans people are looking for care.

It’s because I’m mentally ill.

I live with obsessive-compulsive disorder (OCD) and complex trauma; I’m also transgender. And I’ve found that, at this particular intersection, accessing the health care I need has been an uphill battle.

I’ve been denied care numerous times over the years, under the premise that I was too mentally ill to undergo a major surgery — ignoring that gender dysphoria, an acutely painful experience for many trans people, was contributing to my poor mental health.

It took two years to be placed on a waitlist for surgery, when a therapist finally decided that I was “stable” enough (without any explanation of what that actually means).

And it wasn’t just surgery that was made difficult. Psychiatrists in the past have encouraged me to stop taking testosterone, convinced it was making me “worse.” While hospitalized for depression, I had nurses trying to withhold my hormones because they didn’t feel it was “necessary.”

This last January, I finally got top surgery and I now have consistent access to hormone replacement therapy. But I still live in fear that, should my mental health decline again, I won’t have access to the gender-affirming care that has vastly improved my life and wellbeing.

Frustrated by my own experiences, I started reaching out to other trans people with mental illness to see if they’d encountered similar challenges — and I was horrified by what I found.

“A lot of doctors I saw questioned my ability to handle hormones as someone with a history of depression and self-harm,” Luke, a non-binary trans man in Ontario shared with me.

Could that history really justify someone being denied hormones altogether? I was wondering that, too. So I did a little research on the literature we have. And… it’s not exactly helpful, to say the least.

The World Professional Association for Transgender Health (WPATH) created their Standards of Care. The SOC are, more or less, the most recognized clinical guidelines for treating transgender patients. They advocate for an “informed consent” model: allowing for trans people, once fully informed of the risks and benefits of treatment, to choose for themselves the right path forward.

The standards also advocate for competent treatment of co-existing mental health conditions with the use of therapy and medications, where appropriate.

But if you look closer, you’ll find that they are limited in how they discuss treatment of mentally ill trans people. “Clients should be assessed for their ability to provide educated and informed consent for medical treatments,” it reads, without actually offering adequate guidelines for what this looks like in practice.

It also states that, before surgery is considered for someone with severe psychiatric disorders and impaired reality testing (so delusions or hallucinations, really), “an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated.”

This raises a really important question: How, exactly, do we measure “improvement” in mentally ill trans people?

And if there isn’t significant enough improvement, is a trans person simply in limbo, unable to access transition-related care?

Mentally ill trans people, then, are ultimately left to the whims of whatever mental health clinician they happen to be seeing — with very little recourse if they disagree with that clinician’s assessment of their readiness for care.

The SOC directly list conditions like psychosis, bipolar disorder, dissociative identity disorder, and borderline personality disorder as mental illnesses that could impact “readiness for surgery.”

But in a document of 120 pages, the SOC actually say very little on how, exactly, to assess at what point a mentally ill trans person might be “ready” to access surgery. Until this is made clearer, transgender people are put in an impossible position of deciding whether or not it’s safe to disclose their mental health status.

Interestingly, WPATH — and the overwhelming majority of care providers who work with transgender people — agrees that gender-affirming care is medically necessary. What’s puzzling is that, in almost any other context, mental health status would not preclude someone from medically-necessary care for any other condition.

Gender-affirming care somehow seems to be an exception, reinforcing the notion that trans-related care is “optional.”

The most direct mention of denying access to surgery in the Standards of Care reads, “No surgery should be performed while a patient is actively psychotic.”

This seems to be the only statement that a trans person can point to when they encounter obstacles, but given the other mentions of “readiness” and “improvement,” there are still too many ambiguities— and too many clinicians who aren’t at all familiar with the SOC to begin with.

Not to mention, none of this helps trans people with more severe mental health challenges who still need to access care.

It’s worth noting, too, that disorders like borderline personality disorder — which is flagged as a potential issue in the SOC — include an “unstable sense of self” as a diagnostic criteria, as well as difficulty trusting others and recurrent suicidality.

Coincidentally, these sound an awful lot like issues any trans person could struggle with simply because they are transgender.

In other words? Any trans person could  be denied care if a clinician who’s unfamiliar with this population misdiagnoses them. In fact, at the time at which I was denied surgery, I myself was misdiagnosed as borderline. When that diagnosis no longer applied, I finally found myself on the waitlist.

While some boundaries surely need to exist, the utter lack of clarity in these guidelines means that trans people with any mental health struggle are at risk.

I spoke to Traci Lowenthal, a licensed psychologist that has worked closely with the transgender community. Most of the time, she shared, “mental illness should not be a barrier to getting necessary trans health care.”

The keyword here being, of course, “should.”

When assessing the readiness of a mentally ill trans person to pursue surgery, the most important factors, she says, are safety and the ability to consent.

So long as they can provide informed consent and keep themselves safe (the example she gives is proper hygiene and medication compliance post-surgery), there should be no barrier in accessing gender-affirming care.

“If a person has delusions,” she continued, “it would be ideal if their mental health provider could help them prepare for how those delusions may impact them while they receive medical care and during recovery.”

Compare this to my two-year battle to access surgery. It wasn’t because I was delusional — I was told, in essence, that I was too depressed to undergo surgery. There was no effort made to determine if surgery might improve that depression, and if there could be ways to better prepare for surgery in that state of mind.

The end result? Transgender people are scared to be honest about their mental health. And this has serious consequences.

I spoke with Ghost (a pseudonym), a trans person in Detroit, Michigan, who experiences schizoaffective disorder, delusions, and anxiety. For them, this has meant a constant fear of interference and mistrust in clinicians. “I am absolutely terrified that my mental health status will be used against me [in transitioning],” they explained.

“I’ve already experienced ‘the look’ from a medical professional,” they went on. “The one they use when you tell them [your mental health status], and they’re suddenly very skeptical of you.”

And with disorders like schizophrenia and borderline disorder especially, all of the trans folks I spoke to said they encountered disbelief when disclosing they were transgender, simply because they had one of these illnesses.

Some trans people have resorted to hiding their mental health history, or outright lying about their mental health status to providers. Others postponed psychiatric treatment altogether to ensure they could first transition without interference, which included forgoing psychotropic medications they desperately needed.

The unfortunate reality is, clinicians can’t adequately prepare someone for the specific challenges of medical transition if they don’t know about their client’s mental health status. And of course, when trans people have greater reluctance to seek out psychiatric care during their transition, they’re unlikely to get the support they need for the best possible outcome.

The fact that trans people should have to choose between gender-affirming care OR mental health care is unjust. Access to both is critical, especially for such a vulnerable population.

Trans people face an extraordinary risk for suicide — but if they fear disclosing their mental health struggles, they are likely to suffer in silence. This puts their lives in danger.

And when a trans person with mental illness is, indeed, denied access to care, the path forward is equally unclear.

Florence Ashley, transfeminine activist and LL.M. candidate at McGill University — with a special focus on bioethics and transgender health care policy — highlights just how much of a grey area this is.

Pointing again to the WPATH Standards of Care, she notes, “The only case that WPATH describes as precluding surgery is while the patient is ‘actively psychotic.’”

The rest, she agrees, is murky at best. “As with many issues faced by trans people, the best we can do is extrapolate from sources of law that have yet to be applied to the specific issue,” Ashley said, noting that a case might be made on the grounds of medical liability and professional ethics.

However, there appears to be no legal precedent for trans people specifically to look to when making such a case.

“This really ties back to a core problem in trans law,” she continues. “At some point, policymaking bodies will have to take up responsibility and pass enforceable policies and laws on trans-specific problems in collaboration with trans communities. Otherwise, we’re always going to be left behind.”

It’s evident, then, that more research and attention is needed to properly support trans people with mental health struggles. We need clearer guidelines, direct policies, and competent clinicians who are prepared to work with trans people regardless of mental health status.

For the transgender people who fear that they will not be able to access gender-affirming care, however, this offers very little comfort.

“I’m constantly worrying that someone will look more deeply into my history and see attempts, hospitalizations, a history of self-harm, and take it all away,” Tamsin, trans woman in Vancouver confessed.

While she finally has access to hormones, she fears it isn’t guaranteed. “[It will] cause me at least some anxiety for life.”

signature

heart

Appreciate the blog? Please consider becoming a patron! A dollar a month might seem small, but it helps keep this labor of love going.

Need a therapist? If you follow this nifty link, you can get $50 off your first month of therapy with Talkspace. Not a bad deal! ¯\_(ツ)_/¯ Read more about online therapy with Talkspace here.

I’m queer and asexual. If that’s a problem, by all means, revoke my membership.

It’s Pride month. And for some, their idea of celebrating Pride is telling asexual folks that they can’t identify as queer. Nothing says “happy pride” quite like being pushed out of your own community, right?

I first came out as asexual to my close friends when I was about fifteen years old.

While friends excitedly shared their stories of making out underneath the bleachers, I had yet to feel even an iota of desire towards anyone. Everything I’d heard about “urges” in health class sounded made up to me. When I mentioned this in passing, my (very wonderful) best friend asked me if I’d read anything about asexuality.

What he told me made sense — I just didn’t want it to. I wanted to be like everyone else. What teenager doesn’t?

I felt like I was missing out on an important experience that I was supposed to be having. So I did what I figured I should do — I went out and got myself a boyfriend. I thought if I gave it a try, maybe a switch would flip in my brain. Instead, I hated kissing him so much that I started avoiding him at school. I pretended to have colds to dissuade him, but he stopped caring.

I broke up with him a few weeks later.

Maybe it was just that particular boy, though, I thought. When I found myself developing romantic feelings towards another boy in my grade, I figured this was my best shot at becoming a “normal” teenager. If nothing else, at least I’d know what everyone else was talking about.

But as that relationship went on, I again felt pressured to keep up the charade. The sexual relationship simply felt like the cost of admission — if I wanted emotional intimacy and romance, I had to offer something in return, didn’t I? I forced it. I desperately wish I hadn’t.

This is what “normal” relationships look like, I reasoned. This is what we’re supposed to do.

Like many asexual people who enter into sexual relationships this way, I lost any sense of boundaries and autonomy. I can’t articulate — maybe because it’s too painful — what it feels like to not have ownership over your body, simply because you feel it’s owed to someone else. I didn’t want to lose my partner, and I believed that as long as I kept pretending, he would stay.

I was in that relationship for three years until I finally couldn’t do it anymore. I walked away convinced something was wrong with me.

Should I be dating women? Was gender dysphoria making it too difficult to be close to people? Was I just depressed? I thought about the passion I’d seen in movies and read about in books, the fantasies and hookups my friends described over drinks, and I felt like a piece of me was missing.

When I met my partner Ray seven years ago, I was enamored. They were funny, brilliant, generous, patient, and quickly became my favorite person on the planet. I wanted to spend every waking minute with them.

They were the first person that didn’t treat physical intimacy like the “price” I had to pay to be with them, either. They supported me through my gender transition and I was there as they grappled with chronic illness. We showed up for each other time and time again.

I was never expected to be anything but myself, even if that meant that our Netflix nights only meant chilling in the literal sense. And for the first time, I had exactly what I wanted — a partner in life in the deepest emotional sense. Three years later, our queer asses got married under a rainbow flag. We drank ourselves silly and fell asleep that night, excited for the next chapter of our lives together.

Yes, a rainbow flag. The same flag that now hangs in our living room of our gay little apartment in the San Francisco Bay Area. Bite me.

If I’m not queer, tell me what I am.

When a group of homophobic teenagers in Plymouth, Michigan, tried to run Ray and me over when we crossed the street, what were we then? When bigots pulled over on the road to yell at us as we held hands, what was that? When I wasn’t allowed to see Ray in the hospital because it was illegal to get married and I wasn’t considered “family,” what did that mean?

When society told me time and time again that I was broken because my relationships didn’t look the way that they “should,” what is that called?

When my heart pounded through my chest because I was afraid my family would reject me, does that sound straight to you? When I search the history books for someone who loves like I do and struggles like I did, and I can’t find a single footnote, does that sound like a privilege to you? When I take pride in resisting notions of “normalcy” and revel in my transgressions, what would you say that is?

Are you suggesting I let go of the one word that ever encompassed all these feelings?

Lately there’s been a lot of conversation in the queer community about whether or not asexual people “belong.”

When I hear this, I feel sick to my stomach. I spent years feeling like handing over my body to someone else was simply the “cost of admission,” the natural consequence if I wanted to feel like I belonged, if I wanted to feel loved, if I wanted to be accepted.

I’m now being told that having sex and losing my autonomy are a prerequisite for being queer, too. After spending years being violated just to feel less broken, people in my own community are asking me to do the same if I want to be in good standing and be accepted.

Take my “queer membership card,” then. In fact, I’ll gladly set it on fire and watch it burn before I ever let someone tell me — or any other asexual person — that access to our bodies is the price we pay to be queer.

“Queer” has, for a long time, been a banner under which folks who have been marginalized because of their sexual, romantic, and gender identities could find a sense of community.

If asexual people can’t identify as queer, where should they go when they feel broken? When they’re told that they owe access to their bodies to someone to be “fixed”? When clinicians suggest they need to be “cured”? When they struggle to find anyone like them to assure them that they’re enough exactly as they are? When they grow up wondering if something is wrong with them, the same way that I did?

The fact that ace folks are met with gatekeepers, even in a community that advocates for inclusion, makes it clear that asexuality is just as stigmatized as we’ve been telling you for years.

If my story sounds familiar to you as a queer person, then you know damn well that I’m queer.

And in my years of blogging and publishing about my experiences, not a single one of you questioned if I was part of your community. If you’re doing so now only because I’ve come out as ace, I ask that you reflect on why.

I’m asking you to believe me now, and believe all asexual people when we tell you who we are. When we choose to identify as queer, we do so with intention and purpose. Asexual (and aromantic folks, too) are not a threat to you. If anything, denying us community is what’s most threatening here.

Gatekeepers exist only to reinforce the idea that people don’t belong — and if you find yourself gatekeeping, you should ask yourself who it serves. Because the moment you ask marginalized people to assimilate, forcing them to choose between their identity and their chosen family, I have to wonder what queerness even means to you.

signature

heart

Appreciate the blog? Please consider becoming a patron! A dollar a month might seem small, but it helps keep this labor of love going.

Need a therapist? If you follow this nifty link, you can get $50 off your first month of therapy with Talkspace. Not a bad deal! ¯\_(ツ)_/¯ Read more about online therapy with Talkspace here.

Photo by Sharon McCutcheon on Unsplash.

I didn’t know I had OCD. Here’s why the stereotypes are so harmful.

Eight years ago, I was misdiagnosed with bipolar disorder.

I didn’t completely fill those shoes, but after spending so many years struggling, I was just relieved to have a label — any label — to help me make sense of things. And when none of the medications seemed to work, they told me I was borderline. While I had a nagging feeling that wasn’t exactly right, either, I didn’t know what else it could be.

I was passed around the mental health system, with clinicians throwing their hands up, unsure of why I wasn’t responsive to any of the therapy or medication they offered me.

At one time, I was on seven different psychiatric medications, and yet I was still reporting that I felt deeply hopeless and anxious.

When I was hospitalized a second time, included among my discharge papers was a handout about personality disorders, emphasizing that if I wanted to get better and would just work hard at it, I could “recover.” The suggestion that I was being difficult and simply not trying hard enough made me nauseous.

Through it all, not once did I consider that I might have obsessive-compulsive disorder.

Why would I? My clinicians were so focused on how moody and unhappy I was, they were totally unable to see the forest through the trees. But that’s a harsh reality for people with OCD — one study showed that half of people with obsessive-compulsive disorder cases were misdiagnosed.

Half. Imagine going to the doctor for a serious illness and the odds of your doctor diagnosing you correctly is the equivalent of flipping a coin.

I still consider myself lucky comparatively. Someone who would later become one of my closest friends stubbornly believed that my clinicians were wrong. This friend had OCD, too, and immediately noticed the similarities between us.

At their urging, I started doing research, and I realized two things: (1) Everything I thought I knew about OCD was wrong, and (2) I definitely, definitely had obsessive-compulsive disorder.

catt-liu-1624-unsplash.jpg

Photo by Catt Liu on Unsplash

This turned out to be a critical realization. Because I’d been misdiagnosed for so long, my clinicians had yet to try prescribing antidepressants for fear it would “make me manic.” The one classification of drug I needed most was denied to me for six years.

The type of therapy that was most effective, too, was the complete opposite of what I’d been receiving.

While reassuring someone with anxiety and challenging their assumptions can be helpful, reassuring someone with OCD about their obsessions can actually make them worse. Reassurance-seeking can be a compulsion for many people struggling with the disorder, and enabling those compulsions will fuel the obsession behind them.

In other words? This diagnosis was the difference between me getting better, and me getting much, much worse.

Unlike my previous misdiagnoses of bipolar and borderline, receiving my OCD diagnosis was a huge relief.

It fit in ways nothing else had before. At the same time, it was disturbing to think about how many years it took and how much emotional pain I had endured along the way.

But I don’t think it was just my clinicians’ faults, either. It’s not a disorder that’s well-understood by the vast majority of people.

I’m still amazed that I didn’t catch on sooner; it wasn’t a disorder that was completely unfamiliar to me. In fact, my paternal grandfather had struggled with OCD for most of his life. It got me thinking about how I could’ve missed something that now seems so obvious.

I’d already heard the stories — his need to have his home impeccably, impossibly, even irrationally clean; his repeated, time-consuming hand-washing; his counting every step as he paced back and forth and his insistence on walking a particular number of steps. I’d once heard that because of his extreme phobia of germs, he’d tear up and flush his junk mail down the toilet so that he didn’t have to touch the trashcan (how he preferred the toilet to the trashcan, I’ll never understand).

vadim-sherbakov-30-unsplash

Photo by Vadim Sherbakov on Unsplash

I couldn’t have OCD, I thought. I wasn’t washing my hands over and over again. My room was a mess. I didn’t count my steps. Case closed.

But what most people don’t understand is that obsessive-compulsive disorder isn’t defined by a set list of obsessions or compulsions, but rather, the mechanism that keeps people stuck in that cycle.

The simplified version is something like this: A person with OCD has a doubt that provokes anxiety (“What if I get sick from touching the trash can?” “Does having this thought mean that I’m secretly evil?” “What if I lose my mind and push this person onto the train tracks?”), and to alleviate that anxiety, they engage in a specific behavior to help alleviate the anxiety.

And it might help with the anxiety at first, which our brains really, really like. If something helps us, our brains are inclined to repeat it. But over time, for people with OCD, it takes more and more compulsive behavior to achieve the same effect, which fuels a harmful cycle.

Because we can never know anything with complete certainty, we keep returning to the compulsions to try to alleviate the anxiety.

I can’t know that I won’t get sick, for example, if I touch a trash can, but I can wash my hands to make myself feel better. I don’t know that my partner loves me right in this moment, but I can ask them.

For someone with OCD, this might result in washing their hands more and more, and asking their partner the same annoying questions time and time again to get reassurance.

Certainty is just a feeling. It requires a basic level of trust that most of us have and develop based on experience (I don’t know there isn’t a unicorn in the other room, but I’m pretty sure, based on the number of times I haven’t seen one).

But people with OCD lack that trust around certain issues (because brains are that way, sometimes), which causes us to obsess. We try to conjure up that feeling of safety and certainty with compulsions.

When someone spends a lot of time spiraling in and out of obsessions like this, that’s OCD — and often times, that person might not even realize it.

The tricky thing is that compulsions might not even be perceivable by other people. Some compulsions are entirely mental. Examples of mental compulsions can include repeatedly reassuring oneself, repeating special words or numbers, counting and re-counting, making mental lists, or reviewing thoughts or conversations.

I’ve heard OCD referred to as the “doubting disease,” and that’s really the best way I can think to describe it.

It’s the runaway train of “what if,” and then the absurd amount of time spent trying to resolve that doubt (fun fact: the doubt is never resolved). OCD just isn’t satisfied with 99.9% certainty, though, and will become consumed with the tiniest fraction of doubt, even directly in the face of logic or reason.

At times, I’d become obsessed with the idea that I might harm people, that my cat might die if I left a window open or that I might poison him by accident, that I wasn’t really transgender, that I’d made up my mental illness, that I’d fallen in love with my psychiatrist, that I might lose control and blurt out slurs or offensive statements, that I was secretly violent, that I might stab myself with a knife if I held one, and on and on and on (seriously, the list doesn’t end).

My brain would latch onto any terrible fear or anxiety I had, and then spend an inordinate amount of time obsessing about it, trying to convince or prove to myself that my doubt was or wasn’t unfounded (sometimes I imagine that my brain is like a courtroom, trying to sort out if a crime has been committed or not).

Thoughts are just thoughts, of course, but people with OCD tend to assign a lot more significance to some thoughts than most people do. It’s the way our brains are wired.

The reality is, then, that it’s not the content of the obsessions that matters. It’s the pattern of obsessing and then seeking to resolve the doubt — mentally or behaviorally — that defines OCD, and the extent to which it interferes with our lives.

Limited representation around just how many ways you can have OCD leads to a lot of confusion around what it actually looks like.

The truth is, OCD isn’t as obvious as people think it is.

There are as many obsessions and compulsions as there are people with OCD; no two people with the disorder will have it in exactly the same way. As a society, though, we’re still stuck on this idea that it’s a disorder that’s easily recognized by being quirky, frequently washing your hands, and organizing your bookshelf by color.

I had no idea I had this disorder. So when my clinicians told me I had a mood disorder, I figured it made enough sense. Not perfect sense… but enough.

While my brain ran on this hamster wheel of “what if,” my clinicians saw someone who was moody and agitated. And rather than asking about the content of my thoughts and how I was coping (or in this case, not at all coping), they focused on how those thoughts made me feel.

Of course, that exhausting mental hamster wheel made me feel like shit. Mood disorder it is! Oh, the mood stabilizers aren’t helping? Right. Personality disorder.

But underneath those moods, my brain was tormenting me. And until we addressed the obsessions, I was never going to get better.

It’s not exactly surprising, then, that clinicians are only accurately diagnosing half of us.

Because I’d heard of OCD in everyday conversation so many times, I’d just assumed it was a disorder that must be easy to understand and recognize. That couldn’t be further from the truth, though. It’s a complex, highly individual disorder, and it requires specialized care that many of us just aren’t receiving.

I was hospitalized twice, put on countless medications that would never help, misdiagnosed multiple times, and shamed by medical professionals who believed that my struggles were, in part, a lack of willpower.

And horrifyingly, I was given treatments that made me worse, and were never designed for someone with my particular struggles.

ocdcat.png

My cat, Pancake, really enjoys this book (and so do I!).

I’m extremely fortunate to now have a (totally amazing) therapist that is very familiar with my set of challenges, a psychiatrist who has prescribed medications that have made my life infinitely better, and most importantly, a framework to understand why my brain does the things that it does.

I can’t explain the level of relief that I feel now, no longer viewing my brain as an enemy but, instead, a complicated organ that’s just doing its best to handle the doubt that we all experience to an extent.

We all have obsessions and compulsions from time to time, and OCD is really a disorder of degree, not difference — and knowing this has helped me become a lot more compassionate towards myself.

In that way, I realize that OCD isn’t necessarily an “illness,” as it is a particular difference that we see in brains like mine. And we’re lucky enough to have some great tools to work with to alleviate some of the distressing stuff that comes along with it — for me, antidepressants, exposure therapy, and trauma work have helped immensely.

I had always assumed that I knew what OCD was. But I really had no idea.

It’s not just the hand-washing, stove-checking, lining-up-your-shoes disorder. It’s not quirky or fun — it’s difficult and it can be scary. The more we push this stereotypical narrative, the less likely it is that the majority of people living with OCD will get the care and support that they deserve.

It took me eight years to get the answers I needed. And too many of us are out there, still waiting.

signature

heart

Appreciate the blog? Please consider becoming a patron! A dollar a month might seem small, but it helps keep this labor of love going.

Need a therapist? If you follow this nifty link, you can get $50 off your first month of therapy with Talkspace. Not a bad deal! ¯\_(ツ)_/¯ Read more about online therapy with Talkspace here.

 

Header photo by Hai Phung on Unsplash