The Personal Politics of SRS

I’m afraid I have to collapse the wave function on the whole Schroedinger’s Genitals thing I had going for awhile: I’ve not had lower surgery.

Hopefully, that won’t encourage any creepy love-letters (yes, something I’ve actually dealt with. More than once).

The reason I’m mentioning that very personal, and very uncomfortable-to-mention, information is that it’s important for the context in which I’ve been navigating a lot of complex issues lately. A few weeks ago, I was contacted very unexpectedly and out-of-blue-ishly by the people who handle the assessment process for those in the Vancouver/Victoria area of British Columbia who are pursuing vaginoplasty (aka SRS, GCS, lower surgery, bottom surgery, etc.), and they were asking to set up an appointment for the in-person interview part of the assessment.

For those who don’t know (which is probably only a tiny minority of anyone reading this blog), the process for trans women to access lower surgery, especially when dependent on external financing, requires jumping through a lot of hoops and submitting to a lot of standards and expectations, collectively referred to as “gatekeeping”. This process is, at its surface, all about ensuring that you’re a “good candidate” for the surgery, “proving” that you’re “really” transsexual, “really” psychologically “able” to make the decision and offer informed consent and ultimately cope with a surgery that’s very emotionally intense (especially when viewed from a cisgender male perspective, which has difficulty imagining the procedure as anything other than horrific), “proving” that you’re really “living as a woman” (whatever the hell that means), and “proving” that you’ve really “socially integrated as a woman” (again, whatever the hell that means).

It’s kinda all about making sure you’re not shaking up cisnormative expectations too much, or threatening the larger frameworks of sex and gender more than is considered acceptable. It’s face is “protect the patient from the potential consequences of their decision”.  It’s shadow is “protect cis-patriarchy from what the patient may imply”.

So… I’d an assessment interview to deal with. And suddenly, out of nowhere, the wheels were turning in the process of my having my surgery.

Actually having my surgery.

It’s one thing as an abstract. As a hypothetical question, yes, I know that this is what I want, and, arguably, need. I know that that is the way my body “wants” to be configured. I have the hard reality of those anatomical desires (if you can really call it desire… Signals? Wiring? Programming?) confirmed almost every time I’m aroused. My body “knows” that’s not what the physiological response is “supposed” to be, and it “asks” for sensations and actions my anatomy can’t provide. I have it confirmed every time I take a shower, every time I get dressed, every time I go pee, ever time I adjust my tuck. I know, as a hypothetical question, that keeping my current genital configuration was never going to be what I really wanted, even if circumstances had been different and it was what I needed to accept.

But what this is as a theoretical question becomes very, very different when it begins to become a reality. When you begin to start wondering when your surgery date will be set. March? April? May? By this time next year, I’ll have a fully healed, functioning vagina? Whaaaat?

And the finality of that decision becomes apparent.

I’ve learned a lot in the time since I began living a transgender life. I’ve grown and changed a lot. And a lot of the things I thought I knew about myself, thought were certain and concrete, turned out to be different, or turned out to be fluid.

I believed, for instance, that I was fully and completely androphilic, exclusively sexually attracted to men. That didn’t turn out to be exactly true. I’m now very happy to just call myself “queer” and accept that who I find attractive or sexy or who I love really doesn’t have a whole lot to do with their being a man or woman or non-binary, nor with their genital configuration. I don’t think of myself as bi or as pansexual. I prefer just saying “queer” because that way it doesn’t matter, I don’t have to pin it down. I can just allow myself to experience whatever attractions or desires come along. And I can do so without having to code or designate or even understand them.

I used to refuse discussing, or thinking about, much less considering the implications of, how my body was never really normatively sexed. That I never really was “male-bodied” in the usual sense, and don’t fit into the traditional conceptualization of trans women’s lives, narratives and transitions as being a process of AMAB -> “male socialization” -> endogenous masculinization -> “come out” -> exogenous feminization. I still don’t openly discuss this much, given what I’ve seen of the consequences of trans women admitting to not fitting The Narrative, but I allow myself to know it. To be aware of it.

Just like I’ve stopped letting myself ignore other aspects of my history that used to terrify me. The various “…-survivor” things.

And I believed that I was wholly binary-identified. I’m not sure that’s entirely true anymore. The more confident I’ve become in my sense of who I am and my right to that understanding, its articulation and its embodiment, the more I’ve been willing to let the comfy blanket (or perhaps training wheels is a better metaphor?) of a consistent, all-encompassing Trans Woman identity slip off the parts where it didn’t quite fit. Maybe there are parts of me – parts of my history, parts of my body, parts of my selfhood – that can be considered androgynous, or bi-gendered, or even male. Why not? Would that compromise my validity in any way, or my right to call myself a woman?

“Woman” is the gender that makes sense to me. The only one that makes sense. In understanding myself, that’s the one that fits, that feels like it actually echoes me. I can confidently say that concept of gender, or self, of sex and sexuality, of the body, that’s the one that’s closest to “me”. Through that, yes, I know that for the most part I’m “binary-identified”. I’m a woman. And that’s fine.

But I can’t confidently say it’s fixed, nor can I confidently say it’s absolute. I’m a woman, but I’m a woman with qualifiers (though it doesn’t need to be unqualified, fixed, absolute or certain to count and be real, and I sure as fuck don’t care what anyone else thinks the “requirements” are for being a woman).

I also don’t know if I can say that I’m always going to feel the same.

That’s why suddenly being confronted with the finality of SRS… that’s why it’s somewhat frightening.

I suddenly had to ask myself how much certainty I really had in all of this… in my “gender identity” (I used to think I knew what that meant, but I no longer think gender has intrinsic qualities; it can only express intrinsic qualities), in what I want for my body, in what I want to embody through it. I started wondering about hypotheticals like whether, in lieu of a vulva and vagina, I might want something else, some other genital configuration.

That’s sort of a foregone conclusion, as being poor, and dependent on socialized healthcare, I have exactly one surgeon, one option, one “technique”, available to me. And even revealing that I was briefly considering other possibilities could damage my chances for approval.

Nonetheless, it ended up on my mind. Ultimately, just like I realized that despite the fact that it’s not quite perfect, and not quite absolute, and not quite concrete, I am a woman, I realized that although I’ll never really be wholly certain, vaginoplasty is what I want, what’s best for me, and certainly better than what I’ve got now. It would make me feel better, more right, in my body. And complex questions of gender and self aside, that’s the most basic, most fundamental, and most important point of medical transition: to feel at home in one’s body.

It’s also the most basic of human rights most frequently denied to trans people: the right to physical and medical autonomy. The right to ownership of one’s own body.

It’s in that respect that the personal becomes the political. What does it mean to access lower surgery, to get to be “post-op”, in a world where this is a limited, politicized possibility? Where lower surgery is a means through which people’s physical realities, their bodies, their anatomies, are so often defined and controlled and limited by their socio-economic realities? Where the “post-op” identity has come to carry along with it an enormous amount of cultural baggage, loaded as middle-class and white?

By no means would I have any intention to martyr my body and my rights as a gesture of “solidarity”, and I have deep problems with the way that poor trans women in Canada, the UK, Ireland and other parts of the English-speaking world being able to access lower surgery and some degree of reasonable medical care is characterized as “privilege”. Privilege, as the term is used in social justice discourse, refers to generalized social advantages conferred to one group at another’s expense. Poor Canadian trans women do not access surgery at the expense of poor American trans women. There’s not a power relationship there. In both cases, the privileged party is the wealthy (yes, trans, but especially cis) of each respective nation, who don’t need to worry about where their healthcare is going to come from. Who can pick and choose their surgeons.

However, neither can I take my ability to access surgery (such that my being contacted about my assessment could even come as a surprise!) for granted. It’s an advantage, certainly. I can’t ignore the scores of women I know in the United States who have resigned themselves to never accessing surgery not out of choice, but simply because that’s the reality they have to accept. They don’t have a spare $17,000 lying around, and know they almost certainly never will. That’s something I can’t shake off. I can’t just blithely get wheeled into the operating room without awareness of the fact that it was only the circumstances of my birth, being born on one particular side of the Strait Of Juan De Fuca, that allows this to be a reality.

That allows me to someday feel that much more at home in my body.

That allows me ownership of my body.

Something that should not be in doubt for anyone.

The socio-economic realities for Canadian trans women are different. As said, I know an enormous number of American trans women who likely will never be able to access lower surgery, gatekeeping or not, due to the unimaginable cruelty of the American healthcare system (poised to become even more cruel, with a vicious and hungry little Paul Ryan running alongside Mitt Romney for the White House). Amongst my Canadian trans women friends, however, surgery is not at all uncommon. And like almost all my friends, most of them are on the rough side of the class divide too. Nonetheless, surgery is accepted as something that most of us will be able to get, as long as we play along with the gatekeepy game as defined by WPATH and British Columbia’s insurance providers.

That means not only are the socio-economic realities of Canadian trans women different, the way we relate to our society and systems relative to our class and spending power, but it means that the physical and anatomical and sexual realities of Canadian trans women end up being different too. We end up inhabiting different kinds of bodies.

That’s a difference that a line on a map should not be able to make for someone’s life.

Being Canadian, however, often means living by cultural codes established in the States, by the socio-economics of the States. The differences often go unacknowledged. Much of the world, I’d imagine, just conceptualizes Canada as “kinda like the States, just a bit more polite and cold and nature-y or something” and doesn’t allow it to go much beyond that. Furthermore, the vast majority of trans writing comes out of the United States. The trans discourse is defined by the American conditions, and often that Americo-centrism goes curiously unrecognized, even in otherwise intensely critical and reflective trans-feminist circles. That means I have to navigate the cultural baggage produced by American medical and social injustice whether I’ve been party to it or not. Having lower surgery means accepting a certain kind of conceptualization of who and what I am, regardless of how much bearing that has on my history and experiences.

Dealing with inaccurate and unwanted assumptions is kind of part of being trans anyway, I guess. But living in constant compromise to normativities, misperceptions, assumptions, other people’s narratives… it’s exhausting.

And that is related to perhaps the darkest aspect of going down this road, of taking advantage of this option: it’s conditional. Having socialized medical care doesn’t mean I’m in the position to simply wander into an office and say “Yep! Sign me up for SRS!” and presto, I’m in the operating room. It means that not only do I have to submit to the gatekeeping standards of WPATH, and play those games, jump through those hoops, tell all of those half-truths about myself, occlude all of those potential disqualifiers, it means I have to do the same for the gatekeeping standards of those footing the bill. Not only “prove” that I’m “really” trans enough to be a “good candidate” for surgery, but “prove” I’m “really” trans enough that the taxpayers should cover the procedure. It means going through a lot of very creepy, very humiliating things. Just to be “allowed” what should be a basic human right.

When I began the process of medical transition, it wasn’t difficult for me to obtain the needed diagnosis. I knew I had to do this, and the only language or concepts I really had available were the same ones made available by the same medical community doling out the magical girly pills. I don’t think I could have articulated my feelings outside the accepted narratives even if I tried. I didn’t have the language to do so, nor the self-awareness to have the inclination. I was desperate, I was dying, and it was a direct and immediate need, that I expressed through direct and immediate terms. I was in no position to question it or explore it or think about what it means.

That isn’t the case anymore. At this point, I absolutely have the means and self-awareness to question the process by which I’ll get this approval. That …that and everything else… makes accessing lower surgery an inherently political act just as much as it is a personal one.

What makes me most uncomfortable is I already know I’m going to play along with the process.

What makes me okay with this, confident in doing this, confident in this as a political act despite the demand for complicity in a cissexist construct, is that ultimately, my politics of trans-feminism boil down to the right to make these choices for ourselves. For our own sakes. We’ve already had far far far too many martyrs. Each trans person, each trans body, is an end unto themselves.

It’s a political act, and demands political consideration. But what kind of trans-feminism would it be if it meant that in the end I couldn’t make this choice for myself? In all senses, for myself.

What I want for my body?


  1. says

    I would just add that one of the qualifications usually asked about at an assessment is ‘support’, as in what kind of resources (financial and social) does the trans women have in terms of post-op recovery? It’s a given that a major operation of this kind will include some period of rest and rehabilitation afterwards; and that fatigue, for a good 4-6 weeks afterwards, has often been reported.

    One can understand then why one would want to plan ahead, to ensure that there’s a plan in place for care and recovery. The problem is that, for many reasons of ostracization and isolation, trans women do not have the extended interpersonal networks that many cis people do: family, friends, a medical plan that includes paid time off of work, and so forth. This makes it very uncomfortable, if not altogether disheartening, to know that an assessment will address, in terms of ‘qualifying’, one’s personal portfolio of relationships.

    • A. Person says

      Ouch. This was something I suspected, but didn’t actually know.

      Well, I guess I still have a decade to figure out how to build relationships when almost all forms of social interaction are painful and anxiety-provoking.

      • says

        Be alert to that: in my experience it’s one of the first things they ask. It makes sense, of course, in a gatekeeper-esque kind of way. But be prepared for that line of questioning. It’s a little bit like that scene in the awful /Transamerica/ about “how many friends do you have”? I was able to confirm with a few friends (all cis, incidentally) that they would be willing to act as caregivers, errand runners, and other forms of support, so I was able to offer that as ‘evidence’ that I have a social life.

  2. Nothing says

    That’s deep!

    For some reason I thought you were already post-op. not that it makes any difference about the issues you raised but something you said before about being certain of wanting SRS from the get go came across as being already a done thing for you.

    Anyway, I find your articles deeply insightful about the processes and realities of trans people. Keep it up. The more white cis know nothings like me learn directly from the source, the fewer misconceptions in our culture.

    • says

      Up until recently, I was deliberately obfuscating the issue of whether or not I’d had SRS. Whenever it came up, I carefully worded the sentences to be ambiguous. This is because I considered it nobody’s business but my own. However, now that I’m dealing with this directly, and it’s bringing up a lot of issues, it would hinder my ability to write about this stuff without being able to speak about the context.

      • says

        It’s good to see you posting again, Natalie, on a really juicy topic like this.

        Seeing that I’m still way behind where you are in terms of transition, I’m still frequently getting the ‘Twenty Genital Questions’ (‘Will you?’ ‘Or won’t you?’) which no trans* person should be obliged to answer if they don’t want to, yet it’s almost never acknowledged by the questioner how much of a fucking liberty it is to go around asking for deeply personal and private information of this nature. In a year or two, I suppose the questions I get asked will have morphed from those above, to ‘Have you done it yet?’ ‘Haven’t you had it done yet?’

        *sigh* Nature abhors a vacuum, and cis people abhor the Bohr radius as applied to trans* people’s privates.

        • says

          I have never been asked that question yet although a lot of people now know I’m transitioning (it’s getting harder to hide now anyway). I’m 99% certain what I want to do myself though.

      • Julie-Ann Richmond says

        I wish you the best .
        Thank you for your healing
        A good mantra for after your surgery is
        ” Thank you for my healing ”
        It does seem to work rather nicely !

  3. A. Person says

    This is a good recap/synthesis of several of the topics you’ve been working on over Twitter.

    I completely agree with you about not being martyrs. By holding everyone to some hardline position, we’re just continuing that oppressive control over our bodies. But I do think that as a part of larger trans* community, those who can access that healthcare should help to some degree to open up opportunities. (Something, that is very obviously important to you.)

    I admit I’ve been slightly uncomfortable in your repeated assertion that SRS in the US is coded as middle-class. It’s a little more complicated than that. While SRS is obtainable on lower middle-class incomes, debt and household costs makes it requires long-term (multi-year) saving. (Especially since SRS costs just about as much as a new car, but generally you can’t get credit for surgical procedures. You also generally can’t use HSA funds for trans* medical care.) So a relatively smooth and painless transition including bottom surgery is really only available for the top quintile of American society.

    To bring this back to the personal politics realm, I’m doing respectably well for a single person in the US, but it’s still going to take about a decade before I’m able to afford SRS, and start jumping through the gatekeeping hoops, while still living like a student (mostly because I had to put myself through college and have a truly crushing amount of student loan debt). And that assumes that I don’t lose my job in the meantime. It’s just personally a very scary thing, because assuming all goes as well as I expect, I won’t be able to start feeling comfortable about my body until I’m in my mid-thirties. (HBSer comments about this sort of thing hurt, because I know that I’m the type of person who gets targeted as a cross-dresser trading up.)

    I completely understand the guilt over making that political choice. I feel it frequently in conjunction with my work. I like the work, but some of the jobs make me feel complicit in the societal law & order trends that curtail freedom. (And I feel quite a bit of anxiety about just even expressing those kind of doubts on the Internet.)

    I always appreciate your writing, it often gives me things to think about and different perspectives to consider.

    (Huh. I must be in a particularly open mood tonight. It tends to be pretty difficult to express myself in any kind of forum, even one as relatively safe as a pseudonymous comment.)

    • says

      I don’t know on what basis you’re saying “generally you can’t get credit for surgical procedures”, but it’s not true. Entire companies like CareCredit exist to loan people money for surgery. I paid for about half of my lower surgery on a regular credit card.

      Of course, if my credit was any worse, I might not have had credit cards with high enough limits to pay for surgery. And I’m now dealing with credit card interest and all the other sequelae of being in a lot of debt. So I’m not saying it’s not a lot *easier* for upper-middle-class people in the US to get lower surgery, and it’s also well-nigh impossible for most poor people; and no one should *have* to go into debt to get medical care; but it *is* how a lot of American trans people in the middle are able to access needed medical care.

      • A. Person says

        Thanks for the reply, Tim. I didn’t know about CareCredit. I was more talking in terms of bank loans though. When I went looking for information, I was told there isn’t really any options except the credit card one. And frankly, borrowing a large amount at that kind of APR isn’t really an option. Looking a little bit at CareCredit, it looks like they’re running somewhere between 27% and 30% APR. And possibly half that if you get approved for a five-year repayment plan. According to their payment calculator, you need to make absurdly high monthly payments to pay off during there zero-interest promotional period, and you get hit with all of financial service charges from that period and if I am reading their website right, the accrued interest on the principle during that period.

        I admit I tend to react emotionally to credit and debt. I grew up in a household where a lot of day-to-day living was financed by credit card debt, and the stress didn’t do anything to improve my mother’s emotional/mental stability. She tended to take out her anger on whoever was convenient.

        So I’ve just become the type of person who goes without medical care unless it’s absolutely critical or it fits within my budget.

        • says

          I agree, it’s a very personal decision. It’s stressful for me to have all this debt, but I think it would have added even more stress to my life to go for any longer dealing with genital incongruence. But it’s a trade-off each person has to decide on for myself.

          (I don’t think my interest rate on my CareCredit loan is that bad, but I’d not be surprised at all if they’d gotten worse within the past few months.)

      • northstargirl says

        I definitely understand about the financing. It was why I had to reschedule my surgery twice, and why it finally happened three years after the originally-scheduled date.

        I was afraid I’d get laughed out of the bank if I went and asked for a loan. I had an idea I didn’t have the credit history to get what I needed, as I had a lot more student loan debt and a car payment and didn’t own a home back then. I applied for a personal loan online, but only got approved for half of what I applied for. Had a friend not sent me the rest, I wouldn’t have kept my surgery date. I hated having the debt, and I hated having to fall back on someone else’s generosity, but I sure felt better after the surgery was done.

        As much as the social and bureaucratic hassles of transition got to me, raising the money for surgery was its own special form of misery. I spent a lot of time worrying about it and it was a definite cloud over the process of transition for me. I have a lot of gripes about the modern US health care system, but the way it has limited access to transition-related services and procedures (and the “logic” behind such exclusions and limitations) is something that seriously sets me off.

  4. kristawolffe says

    I want to hug you so bad right now! I wish i could express how much your writing has helped and comforted me and made me feel accepted and understood by at least *one* other individual in this wide, wild place we call…. well…. whatever we call it.

    I am a *very* happy for you!

  5. says

    Hi Natalie!

    Pre-, post-, non-… you’re still just as much a woman, “it’s the only thing that makes sense” as you put it. Surgery doesn’t change that, as I’m sure you’ve been told.

    I can only go by my own experience, which I know is unusual, not the norm, because of the weird biology. There aren’t that many Trans women of any kind who have been judged biologically female before Genital Reconstruction.

    I never considered not having surgery, not from day one. No matter what it took. It was instinctive in a way I can’t explain, and don’t really understand.

    I could have lived without it, though *some* reconstruction was needed to remove cancer risks, and micturation was messy and awkward. But although I could have lived without it, the first and only time I asked myself if I *really* knew what I was doing was when I was in the operating theatre.

    I decided that there was no “back” to return to. I actually fell asleep, emotionally exhausted and at peace, before surgery.

    I didn’t expect it to make a difference, but it did, in my case. Waking up with things feeling RIGHT. I had no idea it would be such a relief, nor that the burden had been so heavy all my life.

    The only good reason for having surgery is for yourself. But you have that sussed out already.

    I’ve since discovered sex, and now much of the world makes far more sense than it did before… but I’d really rather not discuss such a personal issue. You might do the same, but I can’t generalise from my own experience, I’m too odd.

    All the best, to me it sounds as if you’re doing fine though, you’re already at a place many take years of post-op life to get to.

    Hugs, Zoe

  6. alebuhn says

    Hm. I understand how patronizing it must feel, and I have no personal experience with the hoops the process makes one jump through, but your characterization of this gate-keeping still appears a bit one-sided.

    Surely you would not want people to get the procedure without really, really being sure they want it and will be happier with the results, especially considering how much you proceed, immediately after ridiculing the gate-keeping, to stress the finality of it yourself? I have heard of at least one case where somebody subsequently came to regret the step.

    And is the horrific-ness of the operation really “especially” related to viewing it from a cisgender male perspective”? I at least, as a cisgender male, see really no difference in horrific-ness to the reverse procedure – or any other major surgical procedure for that matter. But not in a good way. The idea of somebody operating on a loved one already makes my stomach churn even when it is to save their lives. Considering the effort and the health risks involved, surely a major operation should only be undertaken if it is really, really necessary, so that some serious gate-keeping is reasonable? This is at least not entirely just about oppression and gender roles.

    • That Guy says

      urm- as far as gatekeeping goes- I’ve got this feeling that if you’re prepared to go through all the rest of transition- and all the sexist, cissexist nonsense, the transphobic reactions of your friends and family, then you’re probably more than qualified in proving that you ‘really’ are trans*.

      I mean, it’s not like you walk into the magical gender-reconfigurator machine as Ken and walk out as Barbie (or vice versa), and I am pretty sure nobody’s done the whole trans* thing for shits and giggles given how shitty society treats you.

      ‘appointments’ beforehand should be a purely practical type thing, (I mean practical, not ‘practical’) explaining the mechanics of the operation, aftercare, recovery and the risks associated with surgery.

      The only real ‘gatekeeping question’ at this point, the only single question that should get asked is

      “do you really want this surgery?
      please erase one”

    • emburii says

      How many people who do proceed regret it versus the folks that benefit from it immensely? By your argument we should bar people from having sex unless they go through a comprehensive vetting process, or we should make abortions a harrowing experience (as if they aren’t already). Oh, and to really drive home that comparison; the people judging the sexual partners should all be virgins, and none of the people making the decisions on abortions should be poor or had unplanned pregnancies or health problems. In theory making sure is reasonable, but in practice gender ‘gatekeeping’ disenfranchises and harms way too many people.

      Also, you really should listen to Natalie when she says that part of the opposition is the ‘horrific nature’ to cis males; she’s had to deal with this issue for a while and she knows what she’s talking about. I’ve personally heard otherwise reasonable, socially liberal and compassionate men react with horror at the sheer mention of gender reassignment surgery. One man opined that these people must hate themselves through and through to want to ‘mutilate’ themselves like that, he just can’t (and doesn’t try) to understand the feeling of part of one’s birth physiology not being the best fit for the rest of it. That over-identification/lack of empathy is sadly pretty mainstream and could definitely contribute to ‘gatekeeping’ as a twisted sort of protection in some people’s minds.

    • karadoc says

      The gate-keeping process may well be stressful and intrusive and generally quite unpleasant, but if there was no gate-keeping process at all, I fear that there would be bunch of very unhappy people who’d made an ill-informed decision; and there would be a very pointy finger-of-blame being wielded against various people.

      I agree with That Guy that if a person is willing to go through the rest of the stuff, then “do you really want this surgery” probably is the only question that needs asking – but the way I see it is that the gate-keeping process is there to determine the first part. ie. it’s meant to confirm that the person really is willing to go through the rest of the stuff.

      Bear in mind though, I’m not saying that the current process is ‘right’. I think Natalie is probably right about the ulterior motives. But I think the stated motives are also legitimate, and I do think there should be some form of gate-keeping.

    • nollidge says

      But why for this surgery and not others? Surely there aren’t as many hoops to jump through for, say, plastic surgery, or gastric bypass. Why, then, should this type of surgery in particular be subject to an extra dimension of scrutiny?

      • canadianchick says

        Nollidge (and others) – ALL elective surgery in this country (and in this province) comes with gatekeeping. You’ve happened to pick two I have specific knowledge of.

        very little plastic surgery is covered in BC, and almost none that would be considered “cosmetic”. One that is covered is breast reduction. In order to have it covered you must have a documented history of back and/or shoulder pain and/or rashes and sores under the breasts that lead to infection. Often a psych consult is also required – presumably to ensure that you’re aware that smaller boobs won’t change your life.

        Bariatric surgery, including gastric bypass, also has a lot of gatekeeping. In addition to only qualifying if you meet certain criteria of BMI and comorbidities, you should have a documented history of unsuccessful weight loss efforts. Once youre in the program (a wait of a few years, btw, there’s a shortage of both surgeons & funding) you undergo psych evaluations, consultations with physiologists, physical therapists, internists, nutritionists, and others as necessary. You must quit smoking, begin exercising and keep a diet and exercise log for at least 6 months. If you’ve suffered from PTSD, sexual abuse or other severe psych issues, you must be cleared by a psychiatrist. You’re expected to gain insight into the non-physiological reasons for your weight gain and develop tools to handle them. And only if the surgeon thinks you’re ready for the surgery do you actually get it.

        heck, even joint replacement surgery involves gatekeeping!

        so it’s not only SRS surgery that involves gatekeeping. I’m not in any way qualified to crticize the particular processes used in SRS gatekeeping, but I don’t think gatekeeping in itself is a bad thing, or unnecessary.

    • im says

      I also find the claim that cis horror is the rationale behind the gatekeeping unconvincing. But in general it sounds rather needlessly overwhelming.

      Good luck Natalie Reed! I’m glad you’re on FTB!

    • alebuhn says


      Oh come on, you are comparing sex to this surgery – in terms of health risks and finality? Seriously???

      nollidge, Tim Chevalier,

      I agree – but I would say it should be harder to have risky vanity procedures done! Some of them can go horribly wrong. However, I deliberately did not mention them because comparing them to the topic under discussion seems inappropriate.

      My main point was anyway that one could see the motivation of the gate-keepers in a more nuanced light; there is probably real concern there, at least in some of them, and not just the desire to force everybody into stereotypical roles.

      • says

        You admit yourself that you don’t understand this process very well.

        I don’t feel like going into “why gatekeeping is fucked up 101” here, because this is NOT a post about gatekeeping, it’s a post about the difficulty of making a very personal, very major decision in a politically loaded context. If you want to learn more about it (and you really should learn more about it before diving into debates with experienced trans folks about it), you can search “gatekeeping” in my archives.

        But I will say that it’s sort of silly, and a bit insulting, to a) assume that you know what’s up here more than all the experienced trans people around you all saying “no, this stuff is really messed up”, and b) assume that this process is in practice exactly as reasonably as you’d personally hope/expect it to be.

        Not to mention how it’s a bit silly that you’d actually assume our society, sexist and transphobic as it is, WOULD implement such a policy in a totally reasonable way.

        Yes, one can make some reasonable arguments as to why some degree of gatekeeping might be worth having around. I’d disagree with those arguments, and consider most of them irrational, biased, paternalistic, heavily cissexist/cisnormative, and often heavily ableist too, and have virtually no basis in the actual evidence we have available (like that those who regret lower surgery are an INCREDIBLY TINY MINORITY, and that the reliability and probability of a positive outcome for the patient is ENORMOUSLY high, moreso than the vast majority of common, accepted medical procedures)… but I’d at least accept that the arguments for the point of having SOME gatekeeping are at least more or less reasonable. But there is absolutely NOTHING reasonable or justifiable about the ACTUAL WAY that our REAL LIFE gatekeeping system is ACTUALLY operated, IN PRACTICE, and it takes either incredible ignorance or incredible bias to believe that it is being conducted in a reasonable, justified way.

        • alebuhn says

          Well yes, point taken, and well in advance, which is why I started my comment with the caveat that I have no personal experience. If you say that the way it is implemented is unreasonable, I am inclined to believe you.

          But your post, which admittedly I may have misunderstood, makes it sound as if the motivation of gate-keepers is entirely unreasonable and entirely based on sexism and transphobia, and that I just don’t buy. Medicinal professionals have a duty not to provide complicated and risky procedures if they are unnecessary, starting with the Hippocratic oath and ending somewhere in the jungle of tort law that they have to face in some countries. Many of them also entered their profession because they deeply care about people.

          I am well aware that most of the psychological/decision making complexity resides on the patient side, but there is some on the other side also, and prejudices are not the only variable in play there.

          • says

            So, alebuhn, I’m pretty sure this particular post isn’t meant for an audience of cis people who don’t know much about SRS. It’s not about gatekeepers, like Natalie said; that means it’s not the place to talk all about the gatekeepers’ side of the story. It’s about Natalie, about transgender people, their politics and communities. Please respect that. (That doesn’t mean don’t read, obviously this is public; it means, please check yourself before you comment, and bear in mind that too many off-topic comments may get in the way of discussions that people may really want to have.)

      • emburii says

        No, I am comparing your claim of these gatekeeping measures as necessary to stave off ‘regret’ with other situations that could also cause misgivings in some small part of a group where the larger category is disadvantaged by such stringency applied from outside. You seem to advocate making the larger population miserable and restricting their choice based on what some smaller subsection MIGHT feel, and I was trying to figure out whether or not this is some special pleading for trans* issues or if you’re this authoritarian all around.

  7. Sinéad says

    This couldn’t come at any more of an apt time as now. I’ve learned that Kaiser Permanente will begin offering “Transgender Surgery” in their nomenclature, which the details are forthcoming. One of which I know is that the surgeries will be done in California, at least for those of us on the West Coast. That puts up a barrier, taking time and money to travel from Oregon, that I have to plan for. Two, I’ve tasked myself with finding out whether orchiectomy by itself is covered, and if so will it: a) be done locally and b) prohibit vaginoplasty later on.

    Financially, I don’t know what the costs will be to me. I doubt it will be a simple $10 copay. But there are more costs than what Kaiser charges me. I work a very physical job with lots of on my feet time, bending, lifting. I know that to be safe, when I do opt for vaginoplasty, I will probably want to plan on saving money for two months off from work, not only for healing but to get to a point in dilation where I will be safe being away from home up to 10 hours. So, yeah, I need to save up money.

    Psychologically, I’m just overwhelmed. I never thought I would ever have the option of vaginoplasty. I have even begun to feel sexual again. I can look at pictures of vulvas and not want to kill myself. I begin crying at the thought that this body nightmare may soon be over, if not in a year then not long after.

    Part of me wants the orchiectomy first, because it will mitigate the months while I wait. And I still want to make sure whether that will satisfy my brain.

    Vaginoplasty scares the shit out of me. I worry whether I’ll be able to pee correctly, like what if they fuck up and my urethra points the wrong way. I am scared that won’t dilate enough or rightly. I’m scared of going septic from an infection.

    Am I scared of loss of orgasm? No. I have been functionally asexual for years. Even the times I have masturbated over the years felt more like a burden.

    I will have to go through the psychological gatekeeping again. The last time I did that whole thing was for hormone therapy a decade ago.

    Good luck and stay strong Natalie, I’ll be walking alongside you in spirit.

  8. rork says

    A small matter perhaps, but thanks for this:
    “I don’t think of myself as bi or as pansexual. I prefer just saying “queer” because that way it doesn’t matter, I don’t have to pin it down. I can just allow myself to experience whatever attractions or desires come along. And I can do so without having to code or designate or even understand them.”

    I have a conceit: love that depends on crotch inspection is beneath me.

    • Bia says


      Though love and sexual attraction aren’t always the same thing.

      I’m not personally attracted to male bodies for example but I’ve been in love with a few men, men who are both AFAB and AMAB. There’s a post over on MxPunk’s website about pansexual attraction and I brought some of these points up.

      They are an awesome blogger btw you should check them out.

  9. Sinéad says

    I also wanted to say that the idea being aligned with what might be considered a “binary woman” identity is not mutually exclusive in a non-binary context, unless by “binary” someone explicitly means that non-binary identities don’t exist. I think my identity as a woman exists in a non-binary system. I think the terminology is vague. I think there’s a way we can discuss the variations of gender identity and phenotypes/genotypes of bodies. Our language seems limited in discussing these variations as degrees of masculine/feminine, male/female, man/woman dualities. But we have philosophical means of synthesizing those like the Yin/Yang theory or Heraclitus’s Logos. I mean these semantics don’t have to exist in a dialectical opposition unless we choose to perpetuate that opposition.

  10. Vene says

    Considering the extent of the process and the strictness of it, I think there is a lot of cis protection and horror going on. Some level of gatekeeping may not be a bad idea, in large part so the patient can give informed consent and an official diagnosis can be made. But, the system currently wants far more than that and wants (using trans women here) people to act in very 1950s stereotypical ways (such as wearing a skirt instead of pants, pants are too masculine). I don’t know if this is still done, but in the past there was even an attractiveness requirement. If you didn’t have the “right” look, you don’t get surgery.

    • Bia says

      I’ve been having problems lately with very well meaning cis friends asking me to “come as Bia” as though I’m not being true to myself if I’m not wearing a dress.

      I’m not on hormones and I can’t shave (because of a surgery that has left me with a reoccurring infection). So unless I want to risk an infection if I want to wear more feminine attire, it looks like I’m gender fucking which I’m totally okay with but don’t always want to be doing when I just want to meet a friend for lunch.

      I’d rather just be able to enjoy their company without people staring and acting uncomfortable. That’s one thing I dislike about grues the most, the way they act around someone when they can’t gender that person easily.

  11. BCat70 says

    As a straight, cis male, I want to congratulate you on having thw opportunity to get fully comfortable, and to thank you for providing a perspective in your blog that I have no way of seeing myself. Its funny, but the more I learn about humanity <> the more I do not know.

    On that subject would you be okay with some discussion on “consequences of trans women admitting to not fitting The Narrative” that you alluded to in this post? I may be useful and interesting for your readers.

    P.S. What the hell does cis mean, exactly?

    • D-Dave says

      Hi BCat,

      ‘Cis’ just means ‘not trans,’ and (I think) originally comes from describing molecules in chemistry. Natalie has a glossary up in her sidebar to help out with the terms. I found it very helpful in figuring out what some of our fellow humans have been going through.


  12. Trickster Goddess says

    I went through this process about 5 years ago in Victoria. Since you need the approval of two assessors, they save time by doing a 2 on 1 interview.

    In my case, one of the interviewers was Dr. R., who I believe was previously involved in the old Gender Clinic and I found his questions and responses particularly insulting.

    When asked about pre-transition relationships, I said I had been in a relationship with a woman for 11 years, he exclaimed “Aha! So you enjoyed having sex as a man then!” Which was really stupid, since those nerves down there tingle no matter what your configuration. Was I going to refrain from having sex just because I’m not in the body I wanted? I had to explain my sex life and which types of loving making I enjoyed to deflect his insinuation.

    Then he asked if I thought of myself as a woman when I was having sex. Here we go, I thought, the old Bailey-Blanchard nonsense. I replied that I thought of myself as a woman when I was eating lunch, walking down the street or brushing my teeth, why would I perceive myself any differently just because I was having sex?

    Finally at the end of the thankfully short (15 minute) interview, he says, “Well I think surgery will only slightly be beneficial for you, but I’ll approve it anyway.”

    Thanks for your magnanimity, asshole. I wanted to punch him for his obnoxious attitude, but knowing I had just been given the bureaucratic approval I needed, I wisely restrained myself. When I got outside on the street, I turned and flashed a one finger salute in the direction of his office window.

    Post surgery, I can tell you he was completely wrong. The benefits for me are far beyond slight; my body just feels… right. I no longer even retain any sense memory of what the old genitals felt like.

    By the way, if you have trouble affording the flight to Montreal (or if you have to travel for any medical treatment), the Hope Air charity will cover it for you. I found them to be helpful and efficient. I filled the online application one day, the very next day they phoned me to get the contact info to verify my appointment and the following day sent me an email saying I had been approved and provided the flight reservation information.

    All the best to you.

  13. erikabutler says

    I figured this day would come for you. At this point, I’ve given up all hope on getting SRS, and have been dealing with the realization that I will never be able to have relationships where I can use genitals that make sense. The only solution for me is to distract myself with other things, but I can’t do that if I keep getting confronted with trans women who have access or who are post-op, so I will probably depart from this blog. I’ve been having very strong triggering feelings over the last month about this, that have caused me to rage and destroy some of my own stuff and engage in self-harm and to have suicidal ideations, and also to ruminate on my past–where I didn’t just deal with trans issues but severe mental illnesses as well about which I am simultaneously embarassed and shameful. Of course, they probably wouldn’t let a crazy, disintegrating person like me have SRS at this point, anyway, even if it were funded.

    On web forums, I’ve put known post-op trans women and trans women in Australia, Canada, and the European Union on ignore, because it’s just too triggering at this point, being constantly reminded of my failure and inability. Because of that, I bit you adieu, and think you are a very good, budding writer and yes I think it is good for you to take this opportunity if that is what you really want. Bye.


  14. says

    In the country I live in, the only public, covered route is through a number of hoops and gatekeeping. Some of the bullshit we have to put up with here is in conflict with human rights and is due to change though, but public medical care is still strictly restricted to “true transsexuals”, which I apparently am not. Though I am definitely a transsexual.

    It doesn’t bother me too much. I don’t want any of the suregons we have to fiddle with that anyway. I’d rather save up or get a loan or something to pay for it myself.

  15. Bia says

    While we’re in related territory I have a question for other trans women, that can be answered anonymously as far as I’m concerned. If you don’t want to answer here I can be reached at biadellastone @

    Do you experience dysphoria or even mild discomfort with all all of your genitals or just parts? Does penetration bother you? Either being penetrated or doing the penetration?

    For example I hate my testicles and I experience dysphoria when expected to penetrate a partner. But I don’t hate my penis and I don’t hate being sexually stimulated or being penetrated.

    This has been on my mind for some time and I’ve met a few trans women that became cold to me after expressing this because they think it means I’m not a woman or transsexual.

    • Kizzy says

      I experience dysphoria about all my genitals. I’m okay with giving penetration, but up until recently have not been interested in receiving penetration with my current equipment.

      I definitely experience shame over my genitals, even when they’re appreciated, but I do enjoy having them stimulated (though only in certain ways).

  16. says

    We do what we need to do to be at peace with ourselves.

    It should be that simple. It isn’t, though, since ID still often hinges upon surgery, and that affects your future significantly… but that is changing. But it’s not right that people should feel intimidated about admitting that they’re considering all their options, and it’s not right that we hush up about the negatives of the surgical route because it sounds like “doubt,” so that others go into it without knowing fully what to expect.

    I actually went through this some time ago, proceeded through the transition process up to the time for surgical referral, and then decided to live without surgery.

    This was not popular. I was branded a fraud and told to stop my HRT, detransition, etc. There was a lot of nastiness. It was one of a few things that made me a target both online and locally, before I moved from Edmonton, and is why Mercedes ended up all dented and blue. The whole reason I started blogging was defiance of this.

    And then, few years later, I realized I needed some personal closure, and then proceeded to pursue surgery. In retrospect, I’m not disappointed, but I believe I also could have been happy with an orchie, under certain conditions. The only mandatory thing was that the baggage had to go, if you know what I mean.

    That was my story. No one is obligated to make it theirs. We do what we need to do to be at peace with ourselves.

    To me, the #1 reason to have surgery is if your body squicks you. Some folks get anxiety about their genitals, sometimes quite severely, and surgery is a necessity. If you don’t have that anxiety, or at least not at that extreme, then you have the luxury of choice.

    The plus side? Fitting in the binary helps a lot with relationships. Being non-surgical limits your choices by an enormous amount. Maybe this will change over time, too, but for now, it counts for a lot. And the body makes sense, feels as it should, does what it’s supposed to. I mentioned that I could have been happy with an orchie under certain conditions, but post-operatively, no conditions are necessary.

    The negative side? Aftercare. For your first half year, it rules you. Also, I wish someone had forewarned me about feminine hygiene. The one thing that I do sometimes have trouble dealing with is that.

    So there’s some thoughts, some OT, some relevant, all from outside the usual narrative. We do what we need to do to be at peace with ourselves.

    It should be that simple.

  17. Leo says

    Some confused thoughts on

    “I knew I had to do this, and the only language or concepts I really had available were the same ones made available by the same medical community doling out the magical girly pills. I don’t think I could have articulated my feelings outside the accepted narratives even if I tried. I didn’t have the language to do so, nor the self-awareness to have the inclination. I was desperate, I was dying, and it was a direct and immediate need, that I expressed through direct and immediate terms.”

    I don’t think I have language or concepts that fit. The good parts of the trans community have lots of vocabulary, but no reflection on it, just “you are whatever you identify as, and you can make up new labels as needed” but no way to find out what really applies. The bad parts of the trans community are bad. I’m trying to get some concepts from doctors, because they’re the ones who actually try to answer the question “I think I’m trans, how do I make sure?”. But all your criticisms of gatekeepers are true.

    Direct and immediate terms help. The specialized vocabulary is useful, but only when you can root in in experience. “This good, that ew, this aaaaaugh” is about the extent of my gender self-knowledge now, and even that isn’t on solid footing.

    I do wish people wrote more about their experiences, and not in terms of “I always knew” (how?) or “I couldn’t keep denying it” (why?) or “It just made sense” (what did?). I don’t feel like a man or a woman, I feel like Thomas Nagel running into a genderfucking Batman.

  18. Praedico says

    Good luck with your assessment, Natalie!
    I hope you get what you need, and don’t beat yourself up over having access that others don’t. What would be the sense in not getting it if you’re sure you want it and have access? Denying it to yourself would not grant even one American trans woman access to SRS; it would simply be hurting yourself.

  19. Natasha says

    I’m jealous of you, Natalie, just as I was jealous of the Canadian clientele at Dr. Brassard’s clinic in Montreal who did not have to pay for their surgery where I was there on my dime (actually acquired through “cost of living” financial aid returns on the Master’s degree I am studying for to both raise my salary and pay for my surgery…cost of living indeed). And, sincerely, there are times when the best intentions, the best philosophical arguments for or against something matter not. If you can make that trip and not bear the costs because your government (at least the one in BC because you know that a province or two over and you would not be so lucky) is progressive enough to pay the costs, go and do so.

    And if you have to put on a dog suit and jump through hoops on the back of a pony to get them to stamp their approval, bark and smile and make the pony jump because sometimes you have to put aside pride to get what you need.

    But you know this. As I told someone earlier today, better to be able to complain about dilating than not be able to do it.


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