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The Gatekeepers, Hormones, Standards of Care and the Real Life Test, Lesser Surgeries and Concerns, GRS in General, Mastectomy, Hysterectomy, Clitoral Release, Metoidioplasty, Phalloplasty, Centurion, Forthcoming Surgical Procedures, Aftercare, Legal Name Change, Employment, Marriage And The Transgendered Person, Social Issues, Relating to Men, Relating to Women, Dating, When To Tell, Additional Information

The Female-to-Male Path (Transsexuality)

The following assumes that you are interested in or considering transitioning female to male. Transition is in fact not the only choice available to you. Some choose to live more androgynously as genderplayers, and challenge the notions that society has about gender. Others are happy with part-time crossdressing, either alone, with a significant other, and / or with a community. There are also those who look at the difficulties with transition, the potential loss of friends / loved ones, the social biases they would have to face, and choose not to change (or to wait) -- and they also often become a part of the crossdressing community.

It is the belief of this site that no choice is an invalid choice. A transsexual may have a wider range of experience in some areas than a crossdresser, but that by no means makes the crossdresser's experiences or motivations any less valid. If a transsexual chooses to remain non-operative, that is his prerogative, and does not somehow make him ingenuine. A transsexual who chooses to slip into hiding in society once they pass, or a crossdresser who remains in hiding are no less worthy because they choose to live in stealth -- it takes a very specific type of person to be an activist, and this responsibility should not be expected of everyone. These are all valid choices, and given the exact same circumstances in our own lives, we might be compelled to make those exact same decisions. Ours is a fractured and marginalized community as it is. We need to find our commonalities, respect our differences, and find our strength together (even those living in stealth are more than welcome to the information and support on this site). We are sometimes all that we have.

The Official Process

If you need to transition (whether male-to-female or female-to-male), the official process is long, and you will have to be certain and committed. Once you begin, you make serious changes to your body that often cannot be reversed. Also, the waiting lists for the doctors who oversee this process are extremely long.

That's the bad news. There is good as well. But it is not a decision to be made lightly.

1) The Gatekeepers.

Gender Identity Disorder (transition is currently addressed as a mental health issue) is not something that many psychiatrists deal with. At the moment, the two doctors referred to as the "Gatekeepers" (they may not like that term, it is a colloquial reference) who can start the process, are Drs. M. Warneke and J.H. Brooks. Dr. Brooks is working one day a week. Both doctors are based in Edmonton -- Dr. Warneke at the Gender Identity Clinic at the Grey Nuns Hospital and Dr. Brooks at F.A.C.S. downtown. There seems to be no new developments in doctors taking up the practice in Calgary.

In order to see them, you will need to get referred to them by your G.P. If you don't have a family doctor, a walk-in clinic doctor will be able to do so for you as well -- however, every doctor's reaction is different, and some may refuse to do so, or may say they'll refer you, only to later say the referral must have been lost in interoffice mail. It is also possible to get a referral from a psychologist or another psychiatrist.

Once the referral is sent, you may still have to wait a long time for your appointment. Dr. Warneke's waiting list spanned over 9 months at last hearing, and at times has been over 1 year. Dr. Brooks may not be taking on new cases. Do not harass the clinic -- it will not get you seen faster. However, you can call the clinic a week after your referral request to make sure that they received it. You can also request at that time to be put on a cancellation list, meaning that if there is a cancellation sooner, you might be able to get in at that time. It can shorten your wait considerably.

One way to cope with the waiting period is to proceed as best you can with transition with your G.P.'s assistance, preferably also with the help of a supportive psychiatrist or psychologist and an endocrinologist. It is possible to begin your "real-life test" (RLT, i.e. living completely as female) before meeting with Drs. Warneke and/or Brooks (make sure there is a paper trail, so that you can point to an accurate date that you went to living full-time), and it is also possible to find a G.P., endocrinologist or psychiatrist to prescribe hormones and monitor them. In this way, by the time you first meet Dr. Warneke or Dr. Brooks, yours may be more a question of finalizing the details before surgical funding is approved. For one point of reference, Calgary psychologist Dr. Kevin Alderson specializes in Gender Identity Disorder, and has a specialty list for his practice. More doctors can be found on the Trans-Friendly Doctors Lists.

2) Hormones.

Drs. Warneke and Brooks are able to refer you to an endocrinologist once you pass your initial interviews. It is the endocrinologist who prescribes the hormones, and is best able to monitor this part of the physical process. Your G.P. is actually able to do this as well, but many don't as most are unfamiliar with proper hormone levels required for transition, or are relatively inexperienced with this.

It is not recommended to take "black market" (non-prescribed) hormones. However, if you do start doing so, please discuss this with your doctor -- most, if they know that you are doing this, feel ethically compelled to continue the process, so that your health can be monitored.

On the other hand, if you are seeing a doctor for this, make sure to educate yourself on hormone regimens -- Hudson's FTM Resource Guide has several links that will help you glean information on hormone regimes (as well as several other bits of advice) as well as Nick Gorton.org. The Transhealth program in Vancouver also has a PDF which discusses both FTM and MTF hormone regimens. An unfamiliar doctor may prescribe levels too low to be effective.

The effects of hormones always range depending on the types used and the individual physiology. Not everyone will be affected the same way. However, transmen usually do experience significant increase in energy and sex drive, gradual increase in strength, some periods of anxiety and aggressiveness, and some clarity of emotion. If they are genetically predisposed to it, they can experience male pattern hair loss. Facial hair growth will increase over several months, but the amount and quality can be variable. It is possible that after full transition, a person's facial and body hair might still be fine and sparse -- genetics once again play a big part, here.

3) Standards of Care and the Real Life Test.

Current medical practices follow the Harry Benjamin Standards of Care. Currently, the medical community treats Gender Identity as a mental health issue, even though there are now provocative medical theories that may lead to a biomedical theory of causation. The HB SoC guides psychiatrists in this process, and dictates much of how transition is handled. The theory is that there needs to be a real life test, roughly a year in length, in which the patient lives and works full-time as their chosen gender. This RLT needs to be fulfilled before SRS surgery is prescribed, and partial fulfillment of this is sometimes considered required before prescribing hormones or lesser surgeries. There are cases, including patients who are older or with certain medical conditions, in which the gatekeepers might see fit to shorten this period. But the point of it is to make sure that the person transitioning will be able to function, live and work as their preferred gender and that they are fully committed to doing so.

4) Lesser Surgeries and Concerns.

These can differ from person to person. Fortunately, most of the FTM surgeries do not fall under cosmetic classification (top surgery and hysterectomy are covered by health care). Unfortunately, however, transitioning FTM requires several major surgeries (hysterectomy, mastectomy, and a number of options for GRS surgery).

FTMs are lucky in the beginning of the process, because they can pass very quickly (unfortunately, they have the much harder time on the surgery side of things). Testosterone will actually help deepen their voices considerably.

5) GRS.

"Sexual Reassignment Surgery" (or Gender Reassignment Surgery, as it's starting to be called) is very different depending on the direction of transition. For female-to-male transfolk, several surgeries are involoved. The first is mastectomy, the second is hysterectomy, and then there are anywhere between one and three bottom surgeries, depending on the mode preferred. In the case of phalloplasty, for example, the first bottom surgery constructs the male parts using skin grafts taken from forearm or thigh, and the second takes place usually a year afterward, to install a pump for functionality (a third surgery is required to construct the testicles). Unfortunately, the bottom surgeries are not as perfected, results tend to be mixed, and satisfaction with this part of the process is much lower than with MTFs. We remain on the lookout for a clinic that has better-perfected this procedure, but much of the trouble resides in the fact that constructing a functioning penis is a very difficult feat to accomplish.

Maybe someday, we can do transplants. :D

The doctors at the GRS clinic in Montreal have an excellent website which has a Flash-based function that details the procedures that they perform.

As of April 7th, 2009, the Province no longer funds Gender Reassignment Surgery. There is a Facebook group dedicated to the effort to restore funding. If you have started transition with the aim toward surgery, or if you are affected in any way by the government's decision to delist, you might wish to consider filing a Human Rights Complaint. You can contact them for more information, or send me a note to be put in touch with people who might have some advice to share specific to the GRS cut.

Before all of this, it is an extremely good idea to get out into the trans community, meet like-minded folks, and get a good feel for whether this is for you. Chances are, you'll meet some great, supportive people, and get a chance to get a balance of information, and some idea of where you will be on the other side of this journey. It is invaluable to have people to turn to with those questions and concerns unique to our process.

Surgical results always depend on the procedures used, and the individual's ability to recover. The older a person is, the less resilient they are, and the more difficulties there can be. FTMs have the unfortunate situation of having several surgeries to undergo, and the bottom surgeries still have mixed results.

Mastectomy -- For many FTM's this is the first and most life-changing surgery. There's no more binding or layering up and it's easier to pass -- great to be able to wear just a t-shirt in the summer.

There are two main types of top surgery. One is double incision and is better suited for bigger chested guys. Two incisions are made under the pecs and these are used to remove excess tissue and excess skin. The nipples and aeriolas are taken right off, re-sized and grafted back on in the proper location. The downside is that there will always be scars. Depending on how well or badly the person scars and how hairy they are, the scars may or may not be noticable. They do fade eventually. The scars may be two straight or curved lines under the pecs and they may also meet in the middle. Some surgeons are not very good at re-sizing nipples and their patients may end up with 2 circles of aeriola and no actual nipple in the middle but that can be fixed later or just pierce the middle and voila, you have a nipple. Better yet, if your nipples are small enough to pass, just ask the surgeon to leave the nipple attached to the aeriola and just resize that.

(note: although double-incision is a procedure of choice among doctors in Alberta, there is a high rate of failure when it comes to the nipple part of the surgery. The majority of FTMs I've known who had nipples removed during surgery have ultimately lost them and much of the feeling in that region. If you're particularily attached to yours, you might want to see if other procedures are an option.)

The other type of surgery is better suited to small chested guys and comes in a couple of variations, it may be called keyhole or peri-aeriolar and it varies between surgeons and the size of the chest if skin is removed and how much. Some surgeons do this as a two stage surgery, first removing excess tissue by going in at the side or bottom of the aeriola and a few months later after seeing how much the skin contracts they may cut around the aeriola and remove excess skin. If this is done on bigger chested guys, there is too much skin to remove to be able to close it nicely around the aeriola which may result in pleats in the skin and a not so good result. The only scar is around the aeriola so this can be a very nice result if it goes well.

Both procedures might have problems with too much tissue being left or (worse) not enough. Nipples can get infected or end up looking misshapen. With double incision, skin might bunch up at the ends of the incisions (dog ears) and with peri-aeriolar, it might pleat around the nipple. Some surgeons will do fix-ups on their work for free. Otherwise, talk to AHC about needing a revision and see if they will cover it. Most guys will probably not need a revision.

When choosing a surgeon, ask around. The main surgeons doing FTM chests in Alberta have done many and so it would be possible to get in touch with other guys and see actual results from that surgeon. Make sure you are comparing results from guys with your body type and similar size before surgery. You will get better results if you are at your ideal weight and have worked out a bit before surgery but if you don't have the drive to do that, don't despair. We don't all have to look like Brad Pitt.

You should take it easy after top surgery even if you feel good because moving around too much might make you scar worse. You should not be reaching for things or lifting anything heavy for at least a couple of weeks and not lifting weights for at least 6 weeks, 12 would be better. Different people may give you different advice on what to put on your scars. The safest bet is to put nothing at all or use silicone sheets especially sold for scarring. Oils can actually make your scars worse by keeping the scar tissue moist and allowing it to stretch while it's forming. After your scars are healed, you can massage them to break up the scar tissue.

(note: some have tried liposuction in lieu of mastectomy, but be aware that liposuction only takes care of fatty deposits and does not do anything at all about other tissue and ducts. The most serious drawbacks to liposuction are that one lipo is usually not enough, and a person is usually left with loose "bag-like" skin that may not look right when shirtless, depending on original bust size.)

Hysterectomy -- After starting T (testosterone), there should be no more periods -- but sometimes these parts will start to get a bit crazy after a couple of years on T, resulting in cramps and other problems. Some say they masculinized faster after getting the hysto but for most guys, the ovaries should atrophy after starting T and shouldn't be producing too much estrogen anymore. Some believe that a hysto is not necessary for FTM's and it's true that it's not really proven that FTM's have a higher rate of problems with these parts than women but why take the chance? Besides, if you want bottom surgery, you will need the hysto first.

There are two main types of hysto available. Abdominal incision and laprascopically assisted. Some surgeons prefer one method over the other. Abdominal incision requires making a 6" cut on the belly. The scar may be vertical from the belly button down to the pubic bone, possibly in the middle or off a bit to one side. It also could be a bikini line cut, sitting horizontally in the crease between the belly and pubic area. Some guys like the vertical scar better because it can be explained by a variety of surgeries but with the bikini line scar, nobody should really see it anyway. The recovery time is usually around 6 weeks before going back to work.

The laprascopically assisted hysto requires making 3-4 small incisions on the belly to stick in cameras and surgical tools and then the parts are broken up and passed out through the vagina. Some surgeons will say that this method has a higher complication rate but studies show that if a surgeon is properly trained in using it, the complication rate with the two methods is about the same. The recovery time is much shorter, around 3 weeks.

What should be removed during an FTM hysto is the uterus and cervix along with the ovaries. During recovery, it's good to walk a lot but not too many stairs, no running and no lifting. Make sure you have moved things around in your house so you will not have to reach or bend for things too much and that you have stocked up on groceries.

Clitoral release -- Testosterone causes the clitoris to grow, sometimes it ends up being 2-3" long. The surgeon can release the clitoris from the body to make it feel more like a small penis. When this is done and nothing else, that is called a clitoral release. The vagina and urethra are not touched for this operation.

Metoidioplasty -- This goes a step further than clitoral release to reconfigure the genitals to a male configuration. The vagina is closed off by scraping the lining out of it and letting it collapse and heal shut. The outer labia is used to make a scrotum. The clitoris is released and lifted up and the labia minora used to form the bottom of the new penis. The urethra is extended to the tip of the new penis using the vaginal lining for the inside of it. This is a fairly small surgery, three weeks in Montreal and back to work anywhere from 3 to 6 weeks after surgery. Testicle implants can be done 6 months later and require another 3 weeks off work but only 3 days in Montreal.

The surgery results in a small penis but normally with excellent sensation. It only utilizes what the person has so if they did not get a lot of growth, it will be very small. Many guys with meta's can not pee standing up through their fly because it's too small to reach. It has some erectile function, but it is often considered not enough for intercourse.

The complication rate is maybe around 50% and complications would usually have something to do with the urethra. Scar tissue can constrict the urethra (stricture) or the urethra springs a leak (fistula). Low level strictures can be dilated and low level fistulas can heal on their own. More severe ones might need surgical repair.

Phalloplasty -- The phalloplasty is the only surgery that results in a full size penis, although they normally do not look exactly like a normal penis or function like one. The vagina is closed, the scrotum formed and urethra extended just like when doing a meta but that is where the similarities end. The penis is made from flesh, muscle and nerve tissue taken from elsewhere on the body. The clinic that Alberta Health refers to (Montreal) usually takes the skin graft from a person's left arm, based on a set template. The clitoris is cut off and nerves from it attached to nerves from the arm microsurgically. The new penis will slowly regain feeling as the nerves grow and reconnect.

Before having this surgery, hair removal of the arm is required but if the person is hairy, in most cases the hair tends to grow back. Not that having a hairy penis is the end of the world but it can cause problems in the urethra because the urethra inside the new penis is also made from skin from the arm. The urethra of the phalloplasty is also more complicated than the urethra of the meta because it has two joints, one where the old urethra is extended upwards to the base of the penis and one where the extension connects to the new penis.

For pre-phalloplasty preparation, laser hair removal or electrolysis on the arm hair where the skin graft will be taking place is recommended. Otherwise, the remaining hairs growing back within the urethra can be a painful thing to endure.

If you have smaller arms, it is also recommended to beef them up early. If the phallo template wraps completely around your arm or falls short, it could affect the result of the surgery significantly.

The first part of the surgery is creating the penis. It requires 3 weeks in Montreal. Some guys will need physical therapy for the arm after surgery to get it's mobility and strength back. An erectile implant can be inserted 9 months after the first surgery. A cylinder is inserted into the penis and a pump and reservoir into the belly usually going through the old scar from the hysto. A bulb in the groin is used to pump the fluid from the reservoir into the cylinder to make the penis hard. The testicle implants can be done 6 months later.

The complication rate is almost 100%. Sometimes there are complications with the urethra, stricture or fistula like with the meta. Sometimes there are complications with the erectile device. Infection can also happen both with the penis and arm. Normally the complications can be worked out and everything works out in the end but it can take some time and extra surgeries before that happens.

The scar on the arm will be noticable and people will ask about it but most guys just make up a story about how it happened, got burned, had a car accident etc.

This procedure yields the most realistic-looking result thus far, but is not erectile until the second surgery to insert the prosthetic pump implant. After this appliance is in place and healed, the new penis can be used for vaginal penetration. There has been some development in using a dual pump to strengthen the penis more (i.e. for anal penetration), but this cannot always be done.

Centurion -- The Centurion is a variation of metoidioplasty in which the ligaments from the sides of the labia are freed from the labia majora, and brought together along the clitoris to provide girth for the new penis. This leaves a hollowed-out area for a "pocket" for scrotal implants. The labia major are later joined to form a scrotal sac. A urethral extension to the tip of the new penis is formed by joining skin flaps around a catheter that runs along the underside of the clitoris. The catheter remains in place for about two weeks until the new urethral extension has healed.

It is a natural looking but small penis with full sensation. Erection occurs unassisted. The resulting penis is usually quite small, however, and usually can't be used for penetration.

Currently, this procedure is only being performed by the surgeon who invented it, Dr. Raphael, in Texas.

Forthcoming Surgical Procedures -- When information about new alternatives arise, we will add as much as we can verify.

6) Aftercare.

As with any procedure, there is always risk of infection. With FTM bottom surgeries, especially phalloplasty, it is crucial to watch out for bladder or urinary tract infections, as they can have quick onset, spread rapidly and become severe. Watch carefully for signs of infection and have it addressed as early as possible.

Legal Issues

1) Legal Name Change -- In Alberta, the process requires a number of steps, beginning with fingerprinting, which is done at the central Police Station in your area. For legal name change situations specifically, you will need to make an appointment for this purpose.

Once this is done, you can apply for a legal name change at any Alberta Registry, or through the Alberta Government Services Department of Vital Statistics (10365 - 97 Street, Edmonton, T5J-3W7; 780-427-7013). This will involve a registry fee of $180. You will need to bring with you your fingerprint document, your Birth Certificate, any divorce documentation (if recent and applicable).

Once you receive your Legal Name Change certificate, you can also update the following:

Birth (and Marriage) Certificates. If you were born in Alberta, this can also be done at a registry or through Vital Statistics. You will require your Certificate of Name Change and other proof of identity documents, and have to pay for a new certificate to be issued to you. If you were born outside Alberta, you will need to apply to the jurisdiction where your birth occurred. If you are a landed immigrant, Immigration records are never changed following a name change (to prove your legal name for identification purposes, you will need to provide your immigration papers along with your Change of Name Certificate). To obtain Citizenship documents showing the new name, contact the Canadian Citizenship office for more information.

Social Insurance Number. This can be done at a Service Canada location, such as the one at Canada Place (Edmonton) or 6325 - 103 Street, Edmonton, T6H-5H6. You will require your Certificate of Name Change and other proof of identity documents.

Driver's License. This can be done at any Motor Vehicle Branch or Registry. You will require your Certificate of Name Change and other proof of identity documents.

Alberta Health Care Card. This can be done at an Alberta Health administration location (i.e. Main Floor, 10025 Jasper Avenue, Edmonton) or via the Customer Services Branch, Box 1360, Edmonton, T5J-2N3.

2) Changing the Gender Marker on Your I.D. In the case of most of the above identification, the gender marker ("M" or "F") will not change, until you can present a letter from your surgeon that Gender Reassignment Surgery (GRS) has been completed. On rare occasions, transgender people have had an unthinking clerk change the gender specification on some documentation (i.e. driver's licenses) by mistake, but this is unusual and not policy. You can ask, but until you have the surgeons' letter, you can't expect the gender notation to be changed. This leaves non-operative transsexuals in an unfortunate situation, and some activist groups are working toward gender recognition for those who have lived as their preferred gender for some defined amount of time. There have been some positive precedents of this, including a recent ruling in Great Britain.

The Way We Were Socialized

Although transmen are largely psychologically male, they do not have the benefit of having been socialized (raised) as such by through adolescence, with parents to guide them into what they're supposed to know, and peers to share the things that they're supposedly not supposed to know. This not only means that they are at a disadvantage in the beginning regarding things like dating, male bonding and the like, they are also coming into a world where men are expected to be aloof and stoic, while they once had the ability to be warmer and more expressive.

Relating To Men

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Relating To Women

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Dating And Relating To A Lover Or Potential Partner:

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"When Do You Tell Him/Her?"

The question is first one of IF you need to tell a partner that you've transitioned (or are transitioning) from the opposite gender. People will often have strong viewpoints on either side of this. It's basically an issue of whether you want to 1) tell someone you're interested in now and risk having them run away without ever getting to know you, 2) tell them later and risk having them leave despite all the care and emotion you've invested in the relationship, or 3) never tell them and risk having them find out another way, making them feel often quite betrayed and angry. And honestly, none of the three are particularily appealing. In all cases, the reaction from a potential partner can often be a strong one -- it can even lead to violence.

Although there is the sense of bravado that says "if he (or she) doesn't like it, then it's better not knowing him (or her)," but the truth is that rejection always hurts regardless. What's more, once you're out to someone, your origins in the other gender may become a recurring point of contention in the relationship -- it may be thrown in your face frequently, or your partner may start seeking out your female traits (physical, personality, etc.) and find fault with them, whereas he or she might have remained otherwise oblivious. If this doesn't happen, then at the very least there is still the risk that in your partner's eyes, you might cease to be "the buff guy who likes club music and visiting the art galleries" and become just "the transsexual" -- as if there are no other interesting facets about you beyond that point. This can especially be a problem in that transmen are psychologically male (or at least mostly so), but the stigma of being "transsexual" will often make others think of you more as "female" or "ex-female," than "male."

Everyone's choice is different and valid. There is no shame in hiding a transgendered past -- however, this can lead to the same sense of living behind a mask as the one that drove you to transition in the first place. Also, if your partner can tell that you're hiding elements of your past (i.e. "why don't you have any childhood photos?"), this can sow distrust in the relationship.

IF your partner is ultimately going to find out, either because of the way you pass or because her or his life overlaps your old female life in any way, or for any other reason, earlier is undoubtedly better -- there is always a far greater feeling of betrayal if it is felt that a truth has been hidden for a longer period of time. But it is not necessary to tell someone on day one. You can get to know the person, give them the opportunity to discover what they like about you, and give things the chance to "click." Sometimes, the key to your partner accepting you depends on how badly he or she wants to accept you. And if this person does not know you at all, there is no reason for them to not walk away.

If you decide to tell, it's best to set aside a time, collect your thoughts, and make it special and comfortable for both of you. Let them know how much you value the partnership, and that you want to share something very personal, that you rarely share with anyone else (if, of course, it's true that you rarely tell anyone else). And if your partner sees herself as strictly gay or sees himself as strictly straight, be prepared for this person to need some time to reassess things.

And at that point, all that can be said is, "good luck...."

Additional Resources

Hudson's FTM Resource Guide

Nick Gorton.org: Medical therapy and health maintenance for transgender men -- a guide for health care providers

FTM International

The Transitional Male

FTM Passing Tips

FTM Alliance

TransMan's Information Project

FTM Network (UK)

The Whizzinator Packing Harness: An easy to conceal, easy to use urinating device with a very realistic prosthetic penis.

Important -- Catheter Use and Warnings: University of Ottawa instructions on urinary catheter usage pertaining to some packing devices.

Packing Harness Instructions: To make a cheap packing harness.

Prosthetics for FTM's: A great place to buy soft packs cheap

 

 
     
   
 
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