Further Reflections on the Nature of Post Traumatic Stress Disorder in Transgender Individuals and Implications for Its Treatment

In October of this year, I completed 12 face to face educational hours and 16.5 hours online learning in depth about the nature and treatment of Post Traumatic Stress Disorder. I became a certified trauma counselor through the International Association of Trauma Professionals. I have had an intensive exposure to learning about the nature of Post Traumatic Stress Disorder as a dis-regulation of the Sympathetic Nervous System resulting in a person on a  frequent to continuous basis experiences being in the state of "flight or fight"response.

 The Sympathetic Nervous System is a subdivision of the Autonomic Nervous System. The other half of the Autonomic Nervous System is called the Parasympathetic Nervous System and it's job is to promote a physical sense of calm and well being, and allowing us to be present in the moment when there is no existing threat to us.

Normally, the Parasympathetic is the dominant or default condition of the autonomic nervous system, In those who experience dis-regulation of the Sympathetic Nervous System, it becomes the dominant system. The individual will experience symptoms of anxiety, excessive perspiration or dry mouth, muscular tension, sleep disturbances, feelings of panic and other symptoms of this nature when in reality, no threat exists for the individual.Experiencing these type of symptoms can range from frequently feeling dysphoria of a mild to a severely incapacitating degree.

It is not known at this time the number of transgender people who suffer from the symptoms of P.T.S.D, In my opinion, to the degree that a transsexual has developed a sense of self awareness, the discovery of one's physical body is not of the gender that matches one's gender identity, the greater the degree of traumatization the individual will experience. Similarly, the longer the individual lives with the inability to live authentically and denies one's true identity, the greater the risk for increasing levels of traumatization over the life span.

It is important to be able to identify the type of trauma experience of the transgender person as a complex trauma or as a developmental trauma, so that the type of treatment selection is important.
Developmental traumas do not respond well to psychotropic medications. That does not mean they have no role in the treatment of developmental or complex trauma, it does imply that medications will not be the solution alone in successfully treating this type of PTSD. Medications will be relatively less effective in this type of PTSD over the long term in resolving symptoms.

What is necessary is a retraining of the Autonomic Nervous System to give people more control in activating and learning to stay in states when the Parasympathetic  system is restored to being the dominant division over the Sympathetic system.

When a person is able to exercise more emotional regulation, it is then the therapy can move forward to process and resolve the significance of the past trauma. In part, this is accomplished by the individual recognizing that the past trauma is not occurring in the here and now. As one is able to leave the past behind, the trauma loses its powerful hold on the individual and she is able to continue through the healing process using the techniques learned to manage her levels of reactivity. She is able to be more present in day to day life as opposed to experiencing symptoms of rumination of negative thoughts of the past or future that remove one from what is going on in the here and now. She becomes free to build a brighter future.

An area that I think deserves further consideration and study is whether  the presence of lingering low self esteem or a sense of stigmatization in individuals who have successfully transitioned represents some type or residual state of PTSD that will be extremely treatment resistant.. Is it possible, as Bob Dylan wrote, "You can always come back, but you can't come back all the way..."?

If it can be addressed, it will likely come through cognitive restructuring requiring long term psychotherapy.  The longevity of the treatment will be as important as the frequency of appointments. In psychotherapy that lasts over several years, appointments are held once a week for a long period of time leading to appointments a few times a year over several years after the most intensive part of the therapy is completed. I believe this type of therapy offers the best chance of resolving residual issues of PTSD such as I described above.

I did a literature search on the National Medical Library of the National Institutes of Health and did several fetches using keywords such as PTSD, Transgender and Trauma and found no articles after an advanced search that directly address the concepts I am writing of here. The closest article was an article in a psychoanalytic journal. It is called Mourning the Body as Bedrock;  Developmental Considerations in Treating the Transsexual Patient Analytically. (www.NCBI.NLM.NIH.gov/pubmed/25277869). It suggests that psychoanalytic treatment can be helpful in resolving developmental or complex traumas experienced by transgender people. Research into the treatment of PTSD reveals that many different therapies can be effective in treating PTSD. What is most important is that the therapist be fluent in the modality of of treatment she employs over any particular school of therapy.

In any event, much more research is obviously indicated to help transgender people effectively resolve past trauma and build a future based on mastery over self and the social environment.

The 2015 National Center For Transgender Equality Trans Survey

I'm sorry to have overlooked posting this sooner, but an important opportunity is at hand. The National Center For Trans Equality is seeking respondents for its second survey that is the most important study to identify transgender issues about access to health care, employment discrimination, mental health, substance abuse, public access to activities and education, to name some of the very important things that we as members under the umbrella "transgender" face.

The first survey revealed important information that was brought to public attention and made a tremendous contribution to the expansion of our freedoms and access to healthcare. It is important that no matter how you identify under the umbrella of "transgender" that you participate in the survey, even if you responded to the survey the last time it was offered. Don't believe your voice makes a difference? Maybe not in a lot of circumstances, but here it really does and it is worth the 20 to 30 minutes to take your time and respond to the survey!

A big and heartfelt THANK YOU to Mara Keisling and all the folks at the National Center For Transgender Equality.....

Here is the Link to the survey:  http://www.ustranssurvey.org/

Whose Rights Matter Here?

I saw two news reports today involving two transwomen. In one case the question is raised about the rights of the individual vs. the rights of society, in this case, the rights of other teenage girls to be afforded a dressing room without a preoperative teenage transsexual girl sharing the locker room with them. The other case involves the rights of an adult transsexual woman to complete her transition by having gender reassignment surgery vs. her parents' desire to block her from having the surgery. In that case, a Pennsylvania judge has issued a stay preventing the woman from having her surgery until the case can be heard.

Because the transsexual girl is a minor, I have chosen to delete her name from the news report by the CBS news affiliate who did publish her name. I don't think publishing her name is the proper thing to do.

In the first case, the CBS affiliate in St. Louis, Missouri reports: " Over 150 Missouri high school students voiced their displeasure about a transgender teen using the girls’ locker room by walking out of class.

Students at Hillsboro High School staged a two-hour walkout Monday over 17-year-old  (the student), a student who has identified as a female since she was 13, using the girls’ locker room during gym class.

The school offered (the student) a gender-neutral bathroom, which she turned down. St. Louis attorney Timm Schowalter says, “All students have a right, under Title 9, to access the bathroom of their choice.”

Family members of high school students were also holding a protest.

“Boys need to have their own locker room. Girls need to have their own locker room, and if somebody has mixed feelings where they are, they need to have their own also,” protester Jeff Childs told KMOV. Childs was holding a “Girls Rights Matter” sign.

Tammy Sorden, whose son goes to Hillsboro High School, believes it’s not right to give (the student) special treatment “while the girls just have to suck it up.”

“The girls have rights, and they shouldn’t have to share a bathroom with a boy,” she told the Post-Dispatch."

As a preoperative transsexual myself, I find myself agreeing with the female students of the high school. I don't think they should have to share a locker room with a preoperative transsexual. That is an environment in which there is not the privacy afforded in a regular women's bathroom. This is an environment in which women are fully disrobed in front of each other and I do think it is important to be sensitive to their feelings about this situation. Personally, at this point in my own transition I think it would be terribly disrespectful to subject genetic women and postoperative transsexual women to my presence in the locker room. In the news report or in the protests by the high school students, I do not see any mention of the girls objecting to this preoperative transsexual girl sharing the regular restrooms. This indicates to me that this particular school's students and faculty are rather tolerant of the transsexual students presence in another intimate place, albeit not as intimate as a locker room. To me the transsexual student is being insensitive to the feelings of the very people she is trying to assimilate with. This is not the way to go about it, in my opinion.

In the second case, I will include the name of the transsexual woman because she is an adult.

The Associated Press reports " A transgender woman whose parents went to court Wednesday to block her gender-reassignment surgery in Pennsylvania said she would rather die on the operating table than continue living with male anatomy.

Christine Kitzler, 48, said during a break in the emergency hearing that the risk factors her father raised - including complications from her HIV and Hepatitis C diagnoses - were worth enduring to have her body match the gender she's identified with since growing up in suburban Cleveland, Ohio.

The surgery, temporarily halted earlier this week by a suburban Philadelphia judge as he considers a longer stay, would also save her from backsliding into alcohol and drug addiction, Kitzler said.

Her parents, Klaus and Ingrid Kitzler, contend Kitzler is not competent to make an informed decision to have the surgery because of depression and a childhood learning disorder, and want a temporary guardian named.

"I might die from this. But it's worth dying," Kitzler said. "I would rather die than live the way I was and return to my bad addictions, like alcohol, because I can't do it and I won't do it."

Kitzler's surgery had been scheduled for Tuesday in Pennsylvania, but Bucks County Judge C. Theodore Fritsch Jr. stopped it after her parents' lawyers filed for an injunction and asked for time for reflection before she goes through with what they called an irreversible surgery.

Testifying at the hearing, Klaus Kitzler underscored his concern for his daughter's health. He said he would accept her surgery if an independent psychiatrist deemed her fit to make the decision.

"I accept it, but I want to stop it," Kitzler told the judge. "I would love to have a son back who goes to church with us on Sunday mornings."

Christine Kitzler, who lives in Myrtle Beach, South Carolina, has already been through 16 months of pre-operative preparation, including a 24-hour fast before Tuesday's scheduled surgery, and has received clearances from mental health professionals that she is knowingly and willingly undergoing gender reassignment, her doctor said.

Her lawyer, Angela Giampolo, said she had never seen competency invoked to block a gender-reassignment surgery.

"This isn't a competency hearing. This isn't a guardianship hearing. It's a difference of opinion," the prominent Philadelphia gay-and-transgender-rights lawyer said.

Giampolo said Kitzler's parents are trying to prevent her from living an authentic life. They said they fear Klaus and Ingrid Kitzler want to bring her back to Ohio, win a court action there and permanently block the surgery.

"They have a daughter. They don't have a son," Kitzler said. "I'll have the parts. I am a woman." "

Ms. Kitzler is an adult and she has made a carefully informed decision that having gender reassignment surgery is necessary for her to have a quality of life that makes life itself worth living.

In my opinion, the arguments that she has suffered from depression, has a history of addiction and has a learning disorder are all specious arguments. And here is one reason why the WPATH standards of care exist. 

Let's take this point by point: 1. Ms. Kitzler is an adult and as an adult it is her right to pursue gender reassignment. 2. Show me a person who is transsexual and never suffered from depression to one degree or another. I don't believe there are enough of individuals who have not been depressed in people who are transsexual to be considered statistically significant. 2. Transsexual individuals experience higher rates of addiction and substance abuse than the general population. 3. Having a learning disability in no way impacts the decision to make a gender transition. 4. Having HIV and Hepatitis C infections does not necessarily preclude one from having surgical procedures. 5. None of the above factors generally diminish legal competency.

Because of the guidance of WPATH standards of care, Ms. Kitzler was screened by mental health professionals and found that her mental health and substance abuse issues at this time are not a barrier to treatment and that she is making a well informed and competent decision to pursue gender reassignment surgery. Her physicians have assessed her and found her to be a good surgical risk and are willing to perform the procedure. This should be the end of the story, but it isn't. Her father's sole reason for seeking the court's intervention is that " I just want to have a son who goes to church with us on Sunday mornings." 

If the truth be told, he never had a son, though I do believe he didn't know that for many years. Transsexuals become skilled at living a life and acting out a life that is not authentic. Wouldn't if be more loving and affirming if her father had said, "I'll be looking forward to having my daughter to go to church with us on Sunday morning." 

When this sad episode is over, I'm guessing he will neither have a son or a daughter. My guess is that Ms. Kitzler will never wish to speak to her parents again, or at least for so long a period of time that there will not be much time left in life for them to share. Really, how sad is that? What a terrible thing to happen.

No Depression

If anyone suggested that I experience Christmas, my father's death, my birthday and informing my coworkers that I was transitioning at work in 11 days, I would have told them, "Honey child, there just ain't no way! That idea is a non starter." But, that is exactly what happened. I have drawn a lot of lessons from the experience as well having had other prior positive experiences repeated. Hopefully, sharing this will be helpful to others.

I think that in life we need to use what we experience to make better decisions for ourselves that lead us to find peace within ourselves. Some of us are very stubborn and even though we understand what has happened and the positive lesson we were given, we still resist (for whatever reason) to use it for improving our lives. At times, I have been stubborn about a few lessons along the way, but I have been in a place of total serenity and peace, knowing that things happening would be hard and painful, but also recognizing the stressful positive things that were happening to me as well. Since late fall I have felt this place of acceptance and strength that I never thought I had to draw from. Dana was right; I am a lot stronger than I thought.

What is the difference in 11 days? The passing of my father, whose death I once thought would be so intolerable that I could not imagine how I would be able to function, proved to be a time of strength which I was able to lend to my Mother. There certainly were times that I was overcome with grief, but they were manageable. The gift in the release from his long term suffering was the release from a grieving process that has gone on for 10 years and had become more intense as his condition deteriorated.

Then there were the usual stresses of the holiday season which includes my birthday. I am, however, someone who welcomes my birthday. By all rights, I should not be here as my younger life was led in a careless manner because of the pain of living with the secret that I was not a man. While I was not actively suicidal, I neither cared whether I lived or died and my life was conducted in a careless, reckless way, that should have killed me at least 6 times over. I survived; I have a purpose. I'm glad I figured that out in my 30's and am here to carry out that purpose.

This past year, I dealt with my mother finding out quite by accident my closely held secret. While it was devastating to her, being relieved of that burden became quite liberating after the initial trauma of her finding out was resolved. That was a terribly difficult week.

Deciding that I needed to transition at work was my choice and it has become the most freeing decision that I have ever made. I was afraid when I went to tell my supervisor, but I already knew what she would say and while I was less sure about the hospital administration's response, I was very sure that my coworkers would embrace my decision and I was proven to be right about that surety. The outpouring of love and support through all of these events from the people I work with has been phenomenal and really has changed the way I view myself, as much as my own responsibility for  self acceptance and actions towards self actualizing myself during this short period of time have come to fruition.

To what do I attribute the sense of peace and resolution that I have come to know over this short period of time? I attribute it to my faith and the spiritual crisis last year in the spring that brought me to a deeper examination of an already strong faith coupled with my active determination to find a place to explore my spiritual foundation in a church that loves me as I am without judgment.

Will the way I feel right now last? Mostly. I have no "terrible" secret anymore. Everyone of importance in my life now knows who I am, with the exception of a few people important to me who are not physically close. They will be told very soon when I can arrange the proper  opportunity. for one of these people, I feel a need to tell in person. The others live at a distance too far for me to tell in person and I will soon decide whether to write them individually or to tell them over the phone.

In many ways, our lives can be very painful simply because we live with this fundamental conflict between body, mind and spirit. It is up to us to find  ways to minimize the painfulness of this experience.

The primary truth I have learned is that I have to be who I am, be transparent about who I am to the degree that allows me to live as who I really am, and not be ashamed of who I am. That is not a new discovery, nor is it original. It is one though, I suspect we each have to figure out how to go about for ourselves with the proper support of course, where ever we may find that support. That is part of the uniqueness of our personal journey. The way I have done this may not be the right way for you to go about this, but it is essential that you find a way to find a place where you can live an authentic existence that allows you not to be ashamed of who you are and honors your spirit.

But Enough About Us, Sherri! How About You?

Well my dears, I've had a lot of things to talk about lately, but I haven't been sharing about what I'm doing and what's going on in my life. It's time to catch up!

It's been a rollercoaster in some ways, I have been involved more with my mother and father since my father's heart attack in the beginning of May. We were told that he likely would not live more than six months and more likely two months due to the extent of his decline over all from old age and the failing of several organ systems. He has been ill for years and never recovered from his heart valve replacement which resulted in vascular dementia due to having some strokes during the operation. Because of this, I  have been grieving him for years as I watched him decline and was quite prepared for this perhaps being his last illness. That has been a rollercoaster in that it appeared he was near the end and since then he has rallied, to all of our surprise and it appears possible that he may be able to return home in a month or so. That is where the emotional ride gets bumpy for me as I become more hopeful that he will get better and be more active when he comes home, rather than slide back into his decline. It seems that perhaps being in the nursing home rehabilitation unit has given him much better care than he was getting at home with Mom. I have been making comments to my mother about how well he is doing and that he should stay there until he has gotten the full benefit of his rehabilitation potential, or at least until I return from vacation in mid July. My mother is in significant denial of his health problems and particularly of his dementia. One of the big problems for someone with dementia is apathy and she see's this as his being petulant or wanting to be catered to, which is not the case. He simply has no volition to engage in anything active and the structure of the rehabilitation unit pushes him to be active. As a result, he is more active than I have seen him in the past year. He is appetite is much improved and he is beginning to walk again when he wouldn't move out of his chair at home. I hate to have to say this but I think both he and my mother will both live longer if he stays there permanently. They tend to feed off each other and they both seem highly anxious together. Mom seems to have benefitted with him being away and being under less stress. she is more relaxed and more pleasant.

All of this has taken my full attention and much of my energy.  I have to help Mom more with her home and visit with him, which I don't do enough because after a full day of doing therapy, I have little energy to visit during the week. I do a fairly good job of keeping healthy boundaries and taking care of myself. I do enjoy mowing, being out in the sun and this is my time to meditate, enjoy the sunshine, watch wild life and pray.

What is frustrating about this situation, is it has slowed down my coming out at work, which is the most major task left to accomplish before I can transition there. My therapist Dana, who has helped me so much with managing a lot  the coming out process. She suggests that I start applying for jobs as myself and if I get a job offer then I have a bargaining chip in case the hospital decides they no longer require my services. I think this makes sense. I would like to stay at the hospital, I've been there almost 11 years and have 14 to go so I can have a 25 year pension there. I would also not wish to lose my transsexual patients. I want to be able to continue to coordinate and build upon the comprehensive health program I developed. It would be a loss for me. But it would allow me to live as who I am in that aspect of my life. That is important to me. A lot of my friends will be frustrated to see me throw up a road block delaying my journey. I do have to think about Patty who is unable to work due to disability. I bring home a majority of the income and provide the health care insurance, so it is important to me that I take care of her as best I can. We have huge medical bills.

Of lesser concern is the ongoing and growing realization that there will be a low likelihood of any kind of stealth while I live in this area for a variety of reasons. Not long ago I was introduced to a retired therapist who knew me as a male and is good friends with my department head. That was very uncomfortable to me at the time and I am concerned that my work situation could turn into another coming out at a time and on a field not of my choosing.

Interestingly, (to me anyway) was the fact that last weekend my High School had a reunion of multiple classes with many people with who I went to school. I had absolutely no desire to attend. There are only three people I care to keep up with, three women from my class. The experience of high school was very painful to me as I suffered years of physical and emotional abuse there and no one intervened to stop it, though it was quite visible in such a small school. It has taken years of therapy to deal with it. Therapy helps; I have nowhere near the guilt, shame and anger that I carried for years, nor do I suffer to the extent I have with the severe depression I've had over the past five years.

I was quite interested in the idea of going to one of the events held in a restaurant as myself so I could watch the dynamics and not have them see me. Then I decided they weren't worth it. I would most likely become angry/ sad/ depressed over thinking about what happened to me, so it would serve no good purpose for me.

Looking at the pictures posted on Facebook from the reunion, it dawned on me that if I had gone, it could have been a disaster. It turns out that one of the people from school who was a year or two behind me also goes to my church and is a member of the Vestry (that is a Deacon, for those of us with a Southern Baptist heritage). He knows me now as Sherri and not as who I was. If I had gone, he likely would have recognized me from church and then I would again be in a situation of coming out at a time and a field not of my choosing again and I find that very wearing, as I have written about in the past here.

Soon I do intend to let my three women friends know about me soon and I expect that at that point it will work its way around the alumni of my High School, and that will be ok. The difference being that I told who I wanted to tell who matter to me and if at that point, the rest of them find out, I don't care really.

What I don't like about the situation is my lack of the right to privacy, which we refer to as stealth. I become more and more aware that stealth for me at my age and situation is mostly not going to be. So I have been readjusting my thinking about how important is stealth in my life. After all, even if people do know about who I was, is it really a problem if I am treated as a woman and people interact with me as the woman I am? Is it realistic for me to expect any more given my dual professional identity and my presence in the community I grew up? I think that the expectation of my having a lifw where no one knows of my male past is unrealistic. It sets me up for feeling bad about myself, rather than enjoying the life I should have taken responsibility to have made happen literally decades ago.

The obverse of that coin is that I can't afford to dwell on the "wasted" years. Really? Wasted? No, not really. I have accomplished a lot, both personally and professionally. Rather, it is much better to be living in the moment of now, which is a much happier time in my life and look towards the future in which I will be who I always was, but hid so well.

So what about the man at church I know who went to school with me all those years ago? I think it is time to tell him. That will be good thing, I'm sure.

Meditations While Mowing- On Low Self Esteem

Today, once again, I contemplated playing golf. I have taken it up again a year and a few months since my cervical spinal fusion. I feel so much better and hadn't been able to do outside yard work for the last three years either. My friend "Janet" from college is an excellent golfer and on the state ladies' golf association board. She plays in tournaments around the state and I admire that she has continued to play at a competitive level after having become a recent survivor from breast cancer.



Girls, get your mammogram. Do it for the people you love even if you don't want to do it for yourself. It might be embarrasing the first time, but you will be treated respectfully and while it is uncomfortable, I can think of other medical tests that are less pleasant. If you are without insurance or have low income, your local health department and community hospital can help! For many, there are no costs involved.



One of the benefits of feeling better is being able to mow again. Mowing is something I have enjoyed in my adult life. Plenty of sunshine makes me feel wonderful! I also have time to think about a lot of things and it is a wonderful time to nourish my spiritual condition. This is a very important thing to do at this time in my life with many major changes in process. Being able to mow gives me time to be reflective and mindful of what needs to be done, not only for myself, but for others as well.


I am trying to be a good daughter as we go through my father's final illness. I'm learning many lessons about myself and about taking care of myself. One of the things I have been learning is to take much better care of myself. Today I was sore, decided I shouldn't play golf because of being sore, and I still had a lot of mowing to do. I have a lot to mow to begin with, and I have begun doing Mother and Dad's home so there is one less thing my mama has to worry about.

While I was out there mowing my Mother's huge yard, once again I had my "fingers forcibly pressed upon that firey braile alphabet (Tennessee Williams, Glass Menagarie)" and experienced a uniquely female experience that is uncomfortable. Too much bounce to the ounce.  I wasn't wearing a bra and I need to when I mow. I had my diamond ring on as I usually do but neglected to put it away because of being in a hurry to get their place done and finish up mine. It takes almost five and half hours to do it all.
As I mentioned this gives me plenty of time to meditate and contemplate things that I often don't have the time to think about otherwise. I'm soaking up the sunshine and thinking about things personal and things impersonal.  Sometimes it is a spiritual discipline and I think of the matters that are greater than myself. I spent some time on this today. I thought about those who need help and asked for help for them. I think about the many things I'm grateful for. I think about what I need to do and take responsibility for in order to improve my overall wellbeing.

I spent some time thinking about why so many of us in our community experience low self esteem. I think it develops as a result of our realization that we are different from others, even before we know what that difference is. So we are speaking of people at a very young age when this begins. We know we are different from other boys and girls and we intuitively recognize that most often being different equals bad, especially when the differences are pointed out frequently in something said by the ones important in our lives such as "Why can't you be more like.....??" If you hear that a lot, especially the younger you are, it's going to create feelings that you aren't ok to begin with and then soon after you discover what that difference is. You aren't like the other boys who you are supposed to be like, and you aren't like the other girls who you feel you are like. Quite the internal conflict for a very young person, isn't it?
After a while, it becomes more and more apparent to others and is pointed out to the young person. "You need to act like this because boys...... or don't do that, you are acting like a girl...." Generally, people in this situation are often physically and emotionally abused and sometimes even sexually abused. It creates very low self esteem if it is allowed to go on. It will have life long consequences for that person if it is not prevented from happening or stopped as soon  as it becomes known.

We know that people with low self esteem are much more likely to suffer from depression and anxiety, substance abuse, poor academic and career performance, problems with forming positive and healthy relationships with others, poor self care and increased mortality rates due to suicide and accidents (because people who don't care about themselves aren't careful about their activities). Even when these people are relatively successful in various areas of their life such as career or a sport or with a good relationship, they often have difficulty in seeing themselves as being successful in these endeavors.

Low self esteem is often difficult to treat because it presents in so many different ways as I have pointed out. We professionals tend to treat the symptoms and often don't address the low self esteem that creates the problems. That happens because individuals with low self esteem frequently are unable to identify why they have low self esteem. They know they have it, they need help identifying the lies that were told to them about themselves as well as the ones they told themselves and bought in to so much  that it has become their reality and their "truth" about themselves.



The hard part is being vigilent in identifying these negative beliefs and especially being comitted to replace the self deception with more objective and healthy beliefs about oneself. Yes, we all have things we do poorly, never did well at, and most likely never will. And, that's ok. We have to be objective enough to be ok with that. For example, I will never get to be a medical doctor because of my inability to be able to perform math well enough to have that career, but I have a wonderful career as a therapist, I have been able to help untold numbers of people directly and indirectly. I know I have saved peoples' lives. It's been a very satisfying career for me. I don't dwell on the failure of not becoming a doctor. I am also a very caring person and I go out of my way to help others if at all possible.

The failure is in not also recognizing that we are amazing women in other ways than what we are not good at and being able to celebrate ourselves for those wonderful things that make us good people. Its our responsibility to recognize these wonderful things and to take joy in these qualities. We need to recognize there is nothing wrong with being a transsexual. That took me awhile until I took the responsibility to change how I felt about myself. How about you?

Free Falling

It's been a good run. Over 45 years. It all came to an end quite accidentally, when my mother found one of my business cards for my consulting company, Excellence in Transgender Care (E.I.T.C.) that also has my picture and my last name. There was no mistaking that this was me.  She found this on Monday, and called Patty Tuesday to ask about it. She hadn't been able to sleep that night and was crying while she spoke to my wife on Tuesday. Patty reassured her that she and I are fine, that she is OK with me and she knew about me and that I had a lot of support from my own therapist Dana. 

Patty called me at work and told me to sit down, she had bad news for me and told me what had happened. I was not really prepared to hear this, but was able to continue to be professional and see my last three patients, without any clue that I was upset about this development. It was not the way I would have chosen for my parents to find this out about me and, in fact, have been working in my own therapy on how to go about informing them specifically.

This was also Valentines Day. I had brought cards for Patty from me and the dogs and cats (they each sent a card to her), and I had a card from both of us to Mama. Patty suggested I call her and see if she wanted to talk, but I felt that it would be best to do this on the weekend when I could talk to her alone and without my father who suffers from moderate dementia.

I did want to take her the card from us I had gotten and asked Patty to go with me. I waited a bit to settle down and then called and asked if I could bring her card up to her. She began to cry and told me no. So there was an awkward  silence as I was actually quite stunned that she would not just want me to bring her card to her. So I just said goodbye and told her I loved her. She just said "Ok" and I hung up.

My heart was broken of course over this turn of events. In my two worlds, having worked with families of transgender patients for years, I know how often this scenario ends badly, but often it can work out very well too. The key to a positive outcome seems to lie in allowing parents to work out the emotional trauma that comes along with an unexpected discovery. It's so hard for a parent to realize that they thought they knew this child of theirs who they raised and launched and seen their successes and failures in life, only to discover they really didn't know such an important part of who their child is. They wonder if they ever really knew this child at all. Make no mistake, this is a tremendous loss for most parents and they deserve compassion in order to make sense of this and regain the wholeness of their relationship with their child, if at all possible.

Now they begin the grieving process and go through the stages of grief that Elizabeth Kubler- Ross defined in the late 1970's. In her seminal work, she out lines this process as:         

1. Shock and Denial: Sometimes this manifests as a feeling of surrealism or a factual belief that what is happening isn't or that it can't be true.

2. Anger: This can be directed towards the person or situation that created the perception of  loss, whether it is a death, the loss of an ideal, or can just be a feeling about the situation that really isn't attached to any specific aspect that the person can identify.

3. Bargaining: This can be seen in situations where the person attempts to strike a deal in an attempt to make the painful situation go away and is closely related to the denial process.

4. Depression: During this stage, the process involves losing the cherished ideal of someone or of a situation and despair sets in. In this situation, my parents will never see me again as they once had and are experiencing the loss in an exquisitely painful way. Sometimes people are never able to move past this process in their grief.

5. Acceptance: This comes about when the person is able to reconcile themself to this new concept of how things will be from here on out. It is the healing that comes about from moving through this process and being willing to create a new relationship with the person in the situation. Again, some people are never able to achieve this resolution of what has occurred.

We have to be mindful that people will often move back and forth between these stages as a part of their grieving and that is quite normal. Sometimes people skip some stages and others may never even resolve the first state of this process.

We also must be mindful that people resolve their grief not on our time frame, but their own and we need to be sensitive to that.

When one comes out to someone with such a close relationship, especially not at the time and field of our choosing, we also go through this process. It would be nice to be able to say, "Well OK, it's done and over", but that isn't reality for most of us in these situations. We need to find as much support as we can find for ourselves during this time and we need to really do a super job of taking care of ourselves. That means we need to pay careful attention to our nutrition, don't skip meals even if you don't want to eat. If you can't eat very much, please be sure to supplement with vitamins, especially B vitamins, as they are rapidly depleted when one is going through a crisis. Getting the proper rest is crucial and if one isn't able to sleep, I would advise you to seek medical help because if you can't get your sleep hygiene right, nothing else is going to get better very quickly.

One of the things that is helping me is the tremendous outpouring of love and support I am getting from you, my readers and from members of the transgender community across the country. Please know that I am greatly comforted by this and I'm so grateful and also humbled that there are so many people who care about me. I'm also fortunate to have Patty to lean on and my professional friends and colleagues here who know about me at my hospital. I also am getting tremendous Pastoral care from the clergy of my church who are in daily contact, and of course, Dana too.

I am realistic about this situation. It will be resolved one way or another. While my experience is that many times there are sad and even tragic outcomes with family members, there are many many very happy outcomes as well, even though the process to get there seems bleak at times before it works out successfully and I've learned from my practice that this may take a long time to occur.

Although I am in tremendous emotional pain at the moment, I do know that I will be OK and that what ever way this works out, it will be for the best and my life will be better.  That's the thing about my walk through these two worlds; while I am a well seasoned therapist and have worked with people on these situations, having lived it myself makes me an infinitely better psychotherapist, and all my patients will benefit from this experience, not just my transgender patients. It's one of the gifts I'm being given.

The Long and Winding Road: After the Bell Goes Off

Many of us go through life sitting on the fence about transitioning for years        before we do it. We know who we are, we just aren't sure what we want and/ or need to do about it.

 As Bob Dylan wrote, "Some of us turn off the lights and we live in the moonlight shooting by. Some of us scare ourselves to death in the dark to be where the angels fly..." There are those of us who desperately know what they want, but are so filled with fear over what the implications of recognizing their transsexuality means and what is necessary to resolve the situation that they are paralyzed and live in a state of denial for many years, only to realize much later in life what they must do. Many among us call that "The bell rang or the bell went off". There are those of us for who the bell rang immediately when they realized their female identity and plunge ahead. For some of those people, they intuitively made the right choice. Then there are those who jump in only to find somewhere down the road that they made all the wrong decisions. So they took steps that are irreversible and live with painful regrets. This isn't to say they don't have a feminine identity, but for various reasons they conclude they made a terrible mistake and might not be transsexual.
Various studies indicate that the vast majority of us will never have GRS. The reasons are myriad. Some will never be able to come up with the money and will live in that in between state for the rest of their lives. Others simply have commitments that mean more to them than having GRS, though they dearly desire to be complete. Then there are those whose health is too poor to undergo these procedures, and there are as many reasons true transsexuals cannot fully transition as there are those who choose not to or are unable, too numerous to name here.
Years ago, in my internet searches about information that I could use to help myself, I came across an article written by an anonymous woman who has gone through transition and GRS. I'm not sure I agree with every single thing she said, but from my own personal experience and of the transgender people I've treated or met, I think that there is much wisdom in her article. It is quite lengthy. She makes the point that you either are a woman or you are not. That isn't the question though. The question is: Did your bell go off? I think that is an important insight. If your bell hasn't rung, she believes you should not transition and if it has gone off you will have no choice.
I remember vividly the day my bell rang. It wasn't, as the anonymous author notes, a joyous occasion. My life had been dedicated to not having to do this and I gave it one hell of a shot. I can look back at my football career. When I was 13 I went to preseason practices with the varsity and practiced with them until the J.V.'s started after school began. I got the living hell beat out of me until my freshman year when I lettered on the varsity team the first time, the only one in my class who played on the varsity team. From my sophmore year on, I started both ways on offense and defense. It was great cover for me, or so I pretended.
 Later, I would go on to rock climbing, caving, and I even rode a bull several times. That was nothing but sheer stupidity trying to deny who I am and live that man's life. I lived wrecklessly and honestly should have been killed on at least 5 occasions. I lost my first marriage over this when it didn't go away as I had hoped. I, like so many others thought getting married would make it all go away.
On the day my bell rang, I had been treating transsexuals for 13 years. My thinking was, if I can't do this myself, at least I can help others so they wouldn't suffer any longer as we so often do and live their lives authentically, if that was their right path. Seven years earlier, my dear friend Gianna Israel who is no longer with us wrote me a referral letter for HRT but I didn't use it at the time. I wanted to get on hormones, but the bell hadn't rung yet. I knew it would come, though.  I had returned to therapy and my transsexualism was the reason for my return. I needed to figure out where I was going with all this. Six months into therapy, my bell rang and it rang loudly. I gathered my courage and called the gynecologist I have been referring to since my first male to female patient. I had been referring to her for all of those thirteen years and she was one of the biggest supporters of the work I was doing. I took three days after deciding I wanted to go on HRT to screw up my courage and then I called her. I vividly remember blurting out to her "Melinda, I just can't do this any more, I need your help." She had no idea that I was a transsexual myself, but she is very compassionate and told me, of course she would help. Then I had to go home and tell the person I love more than anyone or anything, more than life itself, what I had decided to do and what I had done about it. Our lives together have never been the same. That is the point of the writer's book.  There will be losses and some will be very painful losses. Be darn sure you are a transsexual before you make the decision to transition . You may possibly lose everything you hold dear. If you are a transsexual, it will be extremely difficult to transition and extremely difficult emotionally not to transition. There seem to be no winners here, at least in the short term to mid term. Recently, I made the comment to Dana, my own therapist, that I was every wife's nightmare. She's heard me make this statement several times and this time she said, "No you aren't. {your wife} loves you and is staying with you. Don't you know any other couples that stay together?" Yes, I do. Besides myself, I know my friend Christina and her wife are successfully working this through, not that it is very easy. I also thought of Christen and Nikki off the top of my head during that session. So, we are not every wife's nightmare.
 I do see a lot of happier women who undertake this rite of passage and successfully transition, but it seems to take a long time to get there from what I can see. Those who do survive the losses and the transition generally tell me they have some improved sense of peace and sense of self as complete and a better quality of life but they always seem to have a bittersweet quality to their lives as well. Others I have known have not fared so well at all.
Here's the link; it's worth the time it take to read it. As I said, I don't agree with all of it, but I think most of it rings true. It's something everyone who is seriously contemplating should read and reflect upon.

http://www.tgchatroom.com/wiki/index.php/So_You_Want_To_Be_a_T-Girl

To Your Health!

One of the more important things that I am both personally and professionally concerned with is the status of our overall well being. It worries me that we don't pay enough attention to our general health and worry most about getting HRT and the surgeries that we want to feel complete. Many of us ignore our health towards this goal by obtaining black market hormones off the street or from pharmacies that sell on line that don't even require a prescription. We don't really know what we are getting from these sources, but the imperative to move our bodies towards a better fit with our minds allows us to take risks risks with our health we would never consider doing otherwise regarding the rest of our health care. It is not entirely our fault, but we share some of the responsibility for this conundrum.

It has been notoriously difficult to find therapists, physicians and other health care providers to provide the care we need, yet more and more health care professionals are willing to treat us and more and more insurance companies are willing to pay for some, if not all of our health care needs on a parity to that comparable with other diagnoses. Many health care systems offer financial assistance based on income. There are also free clinics in many communities that offer health care to those who work, have no insurance and are of limited income. 

When I began working with transsexuals, way before I ever considered that it would be possible for me to transition, I was the only therapist who provided transgender care for the greater part of Virginia. I had one resource for a physician who provided HRT for my male to female patients. I had no resources for my female to male patients, but I had never encountered one until the last 4 years and I was able to find a doctor willing to provide his care.

Today I have developed resources for my patients that include the psychotherapy I provide, substance abuse treatment, treatment for co occurring mental health problems and second letter evaluations (psychiatry), primary care, endocrinology, aesthetic dermatology and voice therapy. Generally, we think of male to female people benefiting from voice therapy, but female to male people can benefit from this service as well. That is because communication within our gender identity does not only include the pitch, tone and inflection, of our voices, but it also includes non verbal communication such as gestures and body movement.

For whatever reason, even if you decide to go the DIYS (do it yourself) HRT route, there are some things that are absolutely necessary and should not be neglected.Please do these to maintain your good health!

1. Blood work: We need to have some blood work done twice a year when first beginning hormone reassignment therapy and after full induction, at least once a year. These tests include a metabolic panel to check the functioning of your organs. The liver and kidneys are particularly stressed by hormone therapy. Having a lipid panel is important as well because hormones can elevate cholesterol and raise the risk of coronary artery disease.

2. Depression, anxiety and substance abuse: These problems are epidemic in our community and we have an overall suicide rate of 41% of those who have attempted suicide at least once. People of color have a much higher rate of attempted suicide than that reported overall.

3. Substance abuse is a particularly severe problem for us and exacerbates depression and anxiety and is often a huge factor in attempted suicides. It has been difficult for us to find substance abuse treatment that is sensitive to us as individuals, but this has been an emphasised area for improvement among substance abuse treatment professionals. This problem is taking too many good brothers and sisters away from us. It is so unnecessary too. There are 12 step programs available. They work for more people than anything else. Check out Alcoholics Anonymous   or Narcotics Anonymous

   . Click on these links to find a meeting near you! http://aa.org/ or http://na.org/ . Some of the groups in some localities are for GLBT people specifically, if you don't feel comfortable with another type of meeting, but if there aren't any of those type meetings available in your area, please don't make that the excuse to not get the help you need. It is truly a matter of life and death.

4. Don't forget your annual mammography! While we generally have a lower rate of breast cancer than genetic women, we are at higher risk with family histories of our moms, sisters and aunts having had breast cancer, especially if they had one of the mutations that cause the more aggressive breast cancers. It is really a painless procedure and will be a life saver. Then there are a couple of tests that we hate as a reminder of having a body we felt was wrong for us. We still have to have the digital examination of our prostate glands. While the risk is reduced, we still are at risk for prostate cancer as we age, even though estrogen and progesterone are treatments used to slow the growth of prostate cancer. We also need to have the PSA blood test done on a yearly basis.

For the guys, it is important to continue to get that pelvic regularly along with a pap smear, and even if you have had a hysterectomy and oopherectomy, you will still need that done periodically, perhaps not as often.

5. See your dermatologist once a year, especially if you have had heavy sun exposure or have a history of skin cancer in your family. It is imperative that you do this yearly if you have has any relatives who had malignant melanoma. This is an extremely dangerous skin cancer and it is too often the case that when it is finally found, it is often too advanced to be successfully treated.

6. See your dentist twice a year! People who are able to keep their own teeth are healthier and live longer. Poor dental health can often lead to heart disease.

7. Don't smoke! It is the most difficult of all addictions to overcome, but it can be done! Smoking is a deceptive addiction, because it doesn't kill you as quickly as some other addictions, but the long term health consequences are devastating and are well known.

8. If you use alcohol, please use it in moderation. Alcohol in any quantity has negative effects on every tissue and organ in the body and is one of the more deadly addictions. Alcohol causes many ruined relationships and injuries due to accidents as well as fatalities. Know when you have had too much and don't be too proud to ask for someone else to drive or take you home. There is no shame in that and it may save some one's life if not your very own life.

9. Get some exercise daily! Even if you can just take 30 minutes and go for a brisk walk, it will improve your overall health as well as cardiac health. It will help you with weight control as well.

10. Be sure to laugh every day! Enjoying humor has been known to benefit general health and one's outlook. Cultivate a positive attitude. It is part of being healthy and attracting positive people. It will be part of being successful and happy in your own life. Smile! positive people are attracted to people who smile and are interested in their well being too.

11. Do something for someone else. It is good for one's outlook and overall attitude to do something nice for someone else. It doesn't have to be anything big, just look for that little opportunity to do something special to help someone else. The return will be ten times what it took to do that little helpful or kind thing!

I hope that you all have a happy and healthy 2012!