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Treatment

If you've been diagnosed with Gender Dysphoria (as I was in August 2001) the obvious question is "what can I do about it?"

Sadly, there's no simple answer. What works for one person may be disastrous for another. One thing is for certain - the more information you have available, the more informed a choice you can make.

When I started out on this long road in 2001 I tried hard to learn everything I could so I knew exactly what I was getting into, particularly from a medical perspective.

I hope to share some of that here. I'll start with an overview of the process from a medical perspective, followed by some of the impliccations (as I understand them) of the two different treatment regimes available in the UK - NHS or Privately Funded.

Finally, I'll describe the specific details of my own transition and the treatment process I underwent.

Transition

The process of changing role in society (in my case from male to female, but the reverse also applies) is known as "Transition".

The definition is a bit blurry, but this process effectively starts when you start preparing for the change (which could be well in advance of starting treatment), and ends when you publicly change your name and public gender role. My transition effectively started in March 2002 when I started facial hair removal (more on that later), and ended on Christmas Day 2002 when I no longer had to pretend to be male.

I won't kid you here - it's a very difficult thing to do, and anyone who attempts it can expect a lot of heartache along the way. Although I've been lucky in that my build and appearance works in my favour, I know others without these advantages who've also transitioned without problems.

Equally, I also know others who've had a very rough time.

Medical Treatment

The physical treatment process for a trans woman can basically involve any of the following:

  • Hormone Replacement Therapy (HRT)
     
  • Facial and (if required) Body Hair Removal
     
  • Voice Training
     
  • Social transition (formerly known as "Real Life Experience", or RLE)
     
  • Genital/Sex Reassignment Surgery (GRS/SRS)
     
  • Facial Feminisation Surgery (FFS) ((an uncommon procedure, but one which can have significant effects on physical appearance and quality of life))

Although the details vary hugely from individual to individual, there is sufficient commonality that an individual can have a fairly good idea of her path through transition, and what is likely to be required for her to succeed. I'm sure I was no exception in that regard.
 

Hormone Replacement Therapy

MtF transsexual patients are usually prescribed female hormones from early in the transition process. If necessary, an anti-androgen may also be prescribed to suppress the effects of male hormones (which are still in the body prior to surgery).

Female hormones affect the body in numerous subtle ways:

  • The growth of body hair reduces drastically (although facial hair is not significantly affected, unfortunately)
     
  • The skin softens and becomes more ?feminine? in texture
     
  • Breast tissue starts to grow
     
  • Facial appearance becomes more feminine
     
  • Fat distribution changes throughout the rest of the body adopt a more "feminine" pattern (for example the hips widen, whilst abdominal fat deposits reduce).
     

Unfortunately, hormones will not affect bone structure (although cartilage can shrink a little, so expect your feet in particular to get a bit smaller!), or the size of the voicebox.

When a patient has been on hormone therapy for several months and her appearance has changed sufficiently, a full-time change in gender role becomes possible.  At this point, a period of "Real Life Experience" (which will be described shortly) is usually started.

It is worthy of note that even after surgery, transsexual people (both men and women) must continue to take hormones since their own bodies will not produce them in the correct amount or balance to maintain their health.
 

Hair Removal

As previously mentioned, female hormones do not have any observable effect upon facial hair growth in MtF transsexuals, and therefore it must be removed in some manner for transition to be practical.

Although short term hair removal methods (through methods such as plucking, waxing etc.) may be practical for some in the short term, a long term solution must inevitably be found. Two of the most common methods available at present are electrolysis and laser hair removal.

Both techniques rely on causing damage to the root of hair cells, thus retarding or stopping hair growth.

Electrolysis achieves this by applying a measured electric charge via a needle inserted into each follicle in turn. Since each follicle must be treated individually, treatment can take a very long period of time (it is not uncommon for facial hair removal by electrolysis to take several years in total).

A further problem is that for treatment to be effective, significant hair growth must be present (at least 2 days, depending on the growth rate) which is obviously a major problem for anyone presenting as female.

Laser hair removal is a newer technique, in which a measured pulse of laser energy is applied to a small area, causing thermal shock to the hair follicles in that area.

In order to transmit the laser energy to the hair follicles rather than the skin (which would cause burns), the wavelength of the laser used is selected to match the absorption frequency of melanin present in the hair follicles. As a result, this technique is only suitable for individuals with dark hair and fair skin.

Although the long term results are not yet proven, laser treatment is much faster than electrolysis due to its speed and the minimal hair growth which must be present for treatment to be successful.
 

Vocal Training and Speech Therapy

Like facial hair removal, voice training is pretty essential in order to transition successfully. However, unlike hair removal a degree of voice training can be undertaken by an individual without outside assistance, although formal speech therapy may be beneficial or required, it really depends upon the individual.

In some cases, vocal surgery is undertaken. However, as the techniques involved are still very new and the results unpredictable,  most patients generally try to avoid vocal surgery if at all possible.
 

Real Life Experience

Before being accepted for reassignment surgery (see below), a transsexual patient must undertake a period of "Real Life Experience" (also sometimes known as the "Real Life Test", or RLT), during which they live completely in the desired gender role for a period of at least a year.

During this period the patient will be, to all intents and purposes, female. Throughout, her progress is monitored by their doctor and psychiatrist, and assuming it is completed successfully and the patient is confirmed to be physically suitable, a letter will be issued certifying that the patient is a suitable candidate for surgery.

Among private patients the Real Life Test commonly starts after several months of Hormone Replacement Therapy. I started on Christmas Day 2002 - just under 7 months after starting HRT.
 

Surgery

Genital or Sex Reassignment Surgery (often referred to as GRS or SRS) is often the final (and irreversible) part of the physical treatment process.

By the time a patient has been accepted for surgery, she must have been living full time "in role" in the community for (according to the Harry Benjamin Standards of Care) at least a year, and have demonstrated her suitability as a candidate for such a major step.

In practice the RLE period is usually significantly longer: patients undergoing NHS treatment have to contend with long waiting lists due to the high demand and small number of NHS surgeons qualified to perform GRS, whilst private patients must save up to pay for the costs of surgery.

In order to further soften the facial appearance, and improve their ability to be accepted by society, some patients may also undergo Facial Feminisation Surgery (FFS). FFS surgery typically involves the reduction of the size of the eyebrow ridges, chin/jawline and nose. The results can have an enormously beneficial effect on the self-esteem of the patient and therefore her ability to fully function in her new role.

GRS/SRS and FFS surgery may be undertaken simultaneously in some cases. Depending on the techniques used, recovery after FFS is normally fairly quick, but GRS/SRS surgery can require a long recovery time (between 6 months and a year to heal full) and a significant time off work (8-12 weeks is commonplace).
 

NHS and Private Treatment

There are two roads through transition in the UK - via the NHS or privately. From the perspective of the patient, the treatment regime followed in the two cases is significantly different, as will be seen in the following sections.

If you opt for NHS Treatment, funding varies considerably between areas. In the past, some would provide funds for psychiatric counselling, but not for treatment. This is now illegal. All Clinical Commissioning Groups must provide treatment, although they may impose unreasonably low quotas or insist patients follow a specific treatment regime. It's a bit of a mess, quite frankly.

As far as I am aware, one essential treatment - facial hair removal - is not generally available on the NHS, so this must be paid for by the patient regardless of whether she transitions under NHS care or privately (this is especially crazy when you consider that it has a profound effect on how well the patient).

Furthermore, the NHS Gender Clinics themselves tend to have long waiting lists, which often results in the transition taking a greatly extended period of time. Possibly as a result of the volume of demand, NHS Gender Clinics tend to require patients to undergo a Real-Life-Experience before receiving hormone therapy, which obviously makes it much more difficult for the patient to be accepted by society.

As a result of these problems, many patients (myself included) attempt to fund their transition privately. Unlike the NHS regime (which tends to be rigidly structured), private treatment places more of the responsibility for her progress through transition on the patient. Hormone therapy is usually started within three months of the first consultation with a consultant psychiatrist, and the Real-Life-Test typically starts several months later.

If the patient copes well with the Real-Life-Test, approval for surgery is likely to follow a year or so after it was started. Since the costs of surgery must be met by the patient herself, in many cases patients will not seek surgery as soon as approval is given - a two year period from the start of RLE seems to be fairly typical.
 

My Own Transition and Treatment

Hair Removal

Since my skin and hair colour is suitable for treatment by Laser Hair Removal, I initially opted to use this technique in preference to the much slower method of electrolysis. From March 2002, each month I visited Christianos Laser clinic in London, with each treatment taking up to 50 minutes including preparation, and costing £220.

Unfortunately, my facial hair proved to be pretty resistant - I had 16 treatments before switching to electrolysis in October 2003 to deal with the remaining hairs. Since hair removal by electrolysis is much more commonly available than laser treatment, I was able to have treatment locally (with Appointments with Vanessa in Farnborough) rather than travel into London, which of course made things easier.

Be warned though: Ten year later, I still see Vanessa for an hour or so a month. Facial hair removal is a very long term process!

I've also had chest and abdominal hair removed by laser treatment, this time by Hairaway (since rebranded as Lasercare) in Shaftesbury Avenue, London. A full treatment cost me £140, and needed to be done every 8 weeks or so. After six treatments of my chest and five on my abdomen, I was largely clear, and I've not had any issues with regrowth in that area.

Prior to my reassignment surgery I also had two sessions of hair removal on my bikini and genital area, and several after.
 

Hormone Replacement Therapy (HRT)

I started hormone therapy under the care of Russell Reid (of the London Institute) at the end of May 2002. Below are details of the hormone regimes I've been prescribed.


Original privately prescribed regime (prescribed by Russell Reid):

  • A now discontinued birth control pill (Ovran) containing 50µg ethinylestradiol (a synthetic form of oestrogen) and 50µg levonorgestrel (a synthetic progesterone), taken twice daily
     
  • An externally applied gel (Oestrogel) containing 0.75mg 17ß oestradiol, to assist in body hair reduction and breast development, applied twice daily.
     

Second privately prescribed regime (prescribed by Russell Reid after the withdrawl of Ovran):

  • A combined birth control pill (Yasmin) containing 30µg ethinylestradiol (a synthetic form of oestrogen) and 3mg Drospirenone (a progesterone with anti-androgenic properties), taken three times daily.

At this point my local GP was refusing to convert prescriptions, possibly as a result of a misguided policy (reversed after I challenged it) by the local Primary Care Trust. This was a particular issue because of the cost of Yasmin - then around £182.50 for a 3 month supply, or around £60.83 a month.

Eventually (with the aid of the Patient Advice Liaison Service or PALS) the PCT relented and agreed to fund it directly - though my GP would still not convert the prescription. The arrangement they came to was quite novel - they arranged for a particular local pharmacy to convert the prescriptions and invoice them directly for the cost of doing so.


Third, abortive regime (it seems I couldn't metabolise Estradiol valerate, and after 3 months on this regime I lost most of my breast development!):

  • Progynova (Estradiol valerate) 2mg three times daily
     
  • Duphaston (synthetic progesterone) 10mg twice daily.
     

Current regime (prescribed by my current GP, with my involvement):

  • Zumenon (Estradiol Hemihydrate) 2mg three times daily
     
  • Utrogestan (natural progesterone in a peanut oil suspension) 10mg twice daily.
     

I'm glad to say that throughout my time on HRT I've not noticed any side effects (other than increased appetite). Aside from the brief period on Estradiol Valerate the HRT has done its work well - I have ended up with a food figure and a natural 36B bust.
 

Real Life Experience (RLE)

When I moved out of the family home at the end of October 2002 I changed my role "part-time" - which effectively meant presenting as female at weekends and in the evening if I was going out. Over time, my confidence improved immensely - I no longer felt self-conscious or anxious by the time I transitioned

For some time beforehand I'd been buying clothes and learning makeup skills, which gave me time to make and recover from the inevitable mistakes along the way, and increase my confidence in my ability to survive the experience and rebuild my life.

I officially started my Real Life Experience on Christmas Day 2002, and I'm glad to say that I didn't encounter any major problems. The problems I did have were emotional in nature rather than to do with others perception of me...I "pass" fairly well and have not faced any hostility. The fact that my appearance and mannerisms have now changed to such a extent that the transition appeared so natural probably helped a great deal in that.
 

Vocal Training and Speech Therapy

Aside from a handful of Speech Therapy sessions at the local hospital, I've not undertaken any formal Speech Therapy. Instead, I researched the techniques involved, ordered a voice training CD and started practicing (by singing in the car while driving to and from work!), with reasonable results.

Based upon what I learn, I came to the conclusion that I could achieve the results I needed to be accepted by society without any form of vocal surgery (which given how risky that is is probably a good thing). In practice, I have found that despite limited success in this area it hasn't been a problem; any fear I had of speaking in public has long since faded, and I've not had any problems from others.
 

Surgery

My reassignment surgery took place on 14th November 2003 with Dr. Suporn in Aikchol Hospital, Chonburi, Thailand, and returned for Facial Feminisation Surgery (FFS) on 21st January 2004.

The results are far, far better than I ever dreamed possible, and I'm now just getting on with life.