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 three doctors referred to as the "Gatekeepers," who can start the process, are Drs. M. Warneke and J.H. Brooks. Dr. Brooks is working one day a week, for medical reasons. 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. There is some information in the medical resources section on doctors who may be able to help you get this referral. 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. Currently (Sept06), he is reportedly not scheduling anything new until after Christmas. 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.

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 most 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 -- particularily those recommendations by medical professionals such as those on Dr. Anne Lawrence's site. An unfamiliar doctor may prescribe levels too low to be effective.

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. Many of them fall under cosmetic, though, and the costs are the responsibility of the person transitioning. Such things include breast augmentation, facial feminization surgery, laser hair removal / electrolysis, hair extensions / transplants / rejuvanation.

In the case of male-to-female transsexuals, it is highly recommended to start facial hair removal as early as possible. Laser hair removal can be particularily effective with a qualified, trained doctor on staff (very few have one -- be choosy, and be wary)... but laser hair removal is only really effective on darker-colored facial hair. Don't be fooled by claims to the contrary, and be aware that this is not a regulated industry. For more information, Andrea James' Hair Facts site is an excellent resource.

For MTFs, it's a good idea to start facial hair removal (laser or electrolysis) before hormones, as the skin becomes more sensitive afterward. Body hair removal is usually not nearly as painful, so afterward is fine.

There are no known cosmetic surgeons willing to do breast augmentations or mastectomies for transpeople in Alberta. We're not currently aware of any in neighboring provinces, either, not even any in Vancouver. Most choose to see the same doctors in Montreal who do the SRS surgeries, but in the case of breast enhancement, it is a completely out-of-pocket procedure (mastectomy for FTMs is covered by Alberta Health). It is not recommended to keep pursuing doctors who are not inclined to perform surgery on transpeople, because if they renege and then choose to do so, there is the risk that they will care less about the outcome, and the patient may have to live with something substandard.

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. For the MTFs, though, estrogen does not have the opposite effect. Transwomen will have to retrain their voices, and this sometimes requires professional voice training, which is available in many venues. In Edmonton, though, there are voice clinics at the Glenrose Care Facility and Grey Nuns Hospital which will allow patients to do so in a facility that is covered by Alberta Health Care (others are not). I do not know at this time if there is a similar center to which transpeople can be referred in Calgary. The Glenrose or Grey Nuns Voice Clinics do require a referral though -- the Gatekeepers can do this, as can your G.P.

The tracheal shave to reduce the appearance of the Adam's Apple in MTFs is not covered by Health Care (if anyone can give me an indication of what the average cost of this is, I'd appreciate it), nor is further cosmetic work. Voice surgery is also not covered, and is extremely dangerous. Many people going this route have experienced long-term damage.

5) SRS. "Sexual Reassignment Surgery" (or Gender Reassignment Surgery, as it's starting to be called) is very different depending on the direction of transition. For male-to-female, they have the very lucky part of the deal here. There is a single procedure, and it has been well-perfected. Results tend to be virtually indistinguishable from the real thing, and success rate has been mostly high. Thorough, extensive aftercare is required, as with any of these surgeries.

For female-to-male transfolk, several surgeries are involoved. The first is mastectomy, the second is hysterectomy, and then there are two bottom surgeries. The first bottom surgery constructs the male parts using skin grafts taken from forearm or thigh, and the second takes place a year afterward, to install a pump for functionality. Unfortunately, the latter surgeries are not as perfected, results tend to be poorer, and satisfaction with this part of the process is much lower. We remain on the lookout for a clinic that has better-perfected this procedure, but much of the trouble resides in the fact that this 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. And in Alberta, SRS is currently covered by Alberta Health Care, for those who are deemed eligible for it.

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.