For Everything There is a Season

As a psychotherapist and program director assisting gender-variant people, I’m often urged to evaluate and recommend for hormone initiation quickly. Quickly, as in, ‘I can’t wait any longer; I’ve been waiting my whole life’.

Sometimes this pressure comes from other therapists working with clients, making it even more challenging—here I am, slowing down a process which involves two other people without having any first-hand knowledge of the situation myself.

It’s All Relative

Thinking of the various pros and cons of our program’s three-month evaluation period for new patients requesting hormone initiation, I developed the following timeline to illustrate some relative timing for crucial (or at least interesting) life events:

A baby learning to walk 12 months
Replacing 100% cells in human body 11 months
Gestating a human 9 months
One year of public education 7-8 months
Driver’s Education (Michigan) 6 months
One college semester 4 months
Evaluation for Hormones 3 months
Average annual television viewing 2 months
Average annual Internet usage 2 weeks
Slow-cooking a pot roast 8 hours
Watching a televised college game 4 hours

 

Faster Than a Semester in College, Slower Than a Pot Roast

For a gender-variant person, initiating hormones can be a significant event that demonstrates forward motion. It is similar to the experiences of coming out to family and friends, beginning to live as one’s destination gender, looking into legal name changes, and dealing with the inevitable questions. Starting hormones is a moment in time to be marked—it is technically the physical beginning of transition.

To rush the stage prior to hormones is to lose some important transition experiences. There is a unique quality to the social and emotional transition period which will never return once hormones are underway.

Similar to early childhood years, when life is fresh and new and exciting every single day, pre-medical transition is infused with the sweetness of ‘firsts’—the first time one is referred to by correct pronouns…the first time Mom uses one’s newly chosen name…the first trip outside dressed in the right clothes…the first time looking into the mirror and seeing the person one is meant to be.

Simply put, these experiences are not to be missed. They are an important part of one’s transition narrative, and to skip them in a rush to hormones is to lose something very, very precious.

That is why we recommend three months, and that is why I hope all transitioning people and their therapists will agree.

“The longer the waiting the sweeter the kiss”…it is a lovely tune, and an important message.

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7 thoughts on “For Everything There is a Season

  1. It’s so true — wanting to start hormones is like an urge, and being told to “stop and wait” can be frustrating. A nice bit of perspective always helps.

  2. Thanks for your thoughtful essay. Despite a great many personal narratives on the subject, it’s sometimes hard to recognize when or if I’m ready for this or that stage of transition. Road maps are all well and good, but how helpful are they without an easily identifiable “You are here” signpost?

  3. >That is why we recommend three months, and that is why I hope all transitioning people and their therapists will agree.<

    Many trans* and especially transsexual people suffering gender dysphoria would not agree. Nor would many care providers. Gender dysphoria (painful distress with one's birth-sex characteristics, birth-assigned gender role, or impaired life function in one's affirmed role) can be debilitating and health-robbing. It can be fatal.

    The WPATH Standards of Care relaxed a previous three month waiting period for hormonal care fifteen years ago in versions 5 (1998), and they eliminated it in the current version 7 (2011). In version 5, hormonal transition care was recognized as a medical necessity, not a cosmetic/elective indulgence. Version 6 added a harm reduction clause to lower barriers to medically supervised hormonal care for those using street hormones:

    "In selected circumstances, it can be acceptable to provide hormones to patients who have not fulfilled criterion 3 – for example, to facilitate the provision of monitored therapy using hormones of known quality, as an alternative to black‐market or unsupervised hormone use."

    For many transitioning people, delayed access to medically necessary hormonal care means prolonged suffering or increased risk from unprescribed hormones. Some cannot function in their affirmed social roles and may be placed at greater risk of physical violence without access to hormonal care.

    Moreover, the rigid requirement for psychotherapy (in addition to assessment, which is still required), before access to hormonal care, was dropped in version 6. Version 7 further clarified this, citing WPATH's 2010 policy Statement of Depsychopathologization:

    “the expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon [that] should not be judged as inherently pathological or negative.”

    One size does not fit all. While far from perfect, the current version 7 of the WPATH Standards of Care provides a more flexible approach to medical transition care that reflects the medical necessity of this care and the diversity of those who need it. It may be downloaded free at
    http://www.wpath.org/documents/IJT%20SOC,%20V7.pdf

    Kelley Winters
    GID Reform Advocates
    gidreform.wordpress.com

    • Kelley, you’re absolutely right that psychotherapy for gender-variant people which is based upon an assumption of mental illness is wrong, wrong, wrong. I’m focusing here on people who come to our program, never having had a chance to talk to anyone about their feelings and who are considering all the myriad details of transition to another point along the gender spectrum. In that case, I believe that 12 weeks to look at all the ways transition will change their lives is time well spent. And I’d add that people who choose to see a therapist with experience in the gender-variant world will benefit most, since no time at all will be spent on any diagnosis of mental illness but rather how the therapist can help the person live authentically and fully.

  4. The ideology represented in this blog post does not account for the personal processing many trans people come to GID clinics with prior to accessing therapy or other medical care. Many trans people, for a variety of circumstances, come to GID clinics having considered hormones for much, much longer than three months (and exponentially longer than cooking a pot roast). My personal experience seeking hormone therapy from an informed consent clinic that did not require a therapy letter was the culmination of a year-long very thoughtful consideration of the way that it would change my life on my own (especially given that I was already being harassed daily for presenting as the other gender but not having my body match). This positions a three-month waiting period as a gatekeeping mechanism rather than any substantial period of reflection for many transgender people.

    I also think that positioning hormones as something that should happen after a string of “sweet firsts” doesn’t take into account that many trans people have very, very different trans narratives. Most of those “sweet firsts” are hard-won and painful and rarely provide the kind of pleasure that other “life firsts” do. Many trans folks, including myself, will never experience that point where “Mom calls you by the right name and pronoun.” Finally, I have a hard time believing that someone would come in seeking hormones without experiencing the “firsts” that are listed in this post, such as wearing clothes that match one’s gender presentation and starting to see what you want to look like in the mirror. Hormones are a huge part in making those “firsts” a common experience rather than an occasional one mixed in with the daily grind of being misgendered.

  5. Neil, thank you for your comment. It is incredibly important to hear all voices on these kinds of topics.

    Perhaps because we are a public clinic (university-based) we have many people who come to us at the very beginning stage of their transition. By that I don’t mean they haven’t been thinking about it for a long time, but that they haven’t done some of the things you list, like wearing the clothes which match their gender identity, or telling people how they feel. Hormones are not a ‘magic bullet’ to create the gender transition experience.

    I wrote this post after a period where many of the new people at our clinic were requesting hormones to begin the process, hoping that irrevocable change would ‘convince’ others that transition was indeed the only path. As a provider, my job isn’t to stop anyone’s process–far from it. My job is to help people as they begin to manage the wide variety of changes around them as they transition, the ripple effect that is easier to see from the outside (where I sit) than the inside (where they live). It is also my job to support and encourage people as they experience the negative reactions from those around them.

    Not every transitioning person needs a clinic like ours. There are many people who are able to find the variety of providers necessary to achieve gender congruence. For those who can’t, our clinic is a place where people can be linked to the medical and surgical providers they may need with mental health support where necessary.

    I believe that what appears to be a blocked gateway is actually a welcoming entry point.

    Again, my thanks for your insightful and heartfelt comment.

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